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THIS  ROOK  IS  A  PART  OP  THI 

LARGEST  PRIVATE  LIBRARY   IN 

JMggftlCA  OM  CANCER  AND 

TUMOR  DISEASE 


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CANCER    AND   OTHER   TUMOURS 
OF  THE  STOMACH 


BY  THE   SAME  AUTHORS. 


STUDENT'S   GUIDE   TO   MEDICAL   DIAGNOSIS.     Ninth 
Edition. 

OUTLINES   OF   MEDICAL   TREATMENT.     Fifth  Edition. 

ULCER  OF  THE  STOMACH  AND  DUODENUM. 

DYSPEPSIA:  ITS   VARIETIES   AND   TREATMENT. 

{In  preparation,') 


CANCER  AND  OTHER  TUMOURS 
OF  THE  STOMACE 


BY 

SAMUEL   FENWICK,   M.D.,   F.R.C.P. 

CONSULTING   PHYSICIAN    TO    THE    LONDON    HOSPITAL 
AND 

W.  SOLTAU   FENWICK,  M.D.Lond.,  M.R.C.P. 

SENIOK   PHYSICIAN    TO    THE    LONDON    TEMPEKANCE    HOSPITAL 

PHYSICIAN    TO    THE    EVELINA    HOSPITAL    FOK 

SICK    CHILDKEN 


PHILADELPHIA 
P.   BLAKIS  TON'S     SON     <fc     CO. 

1012    WALNUT'  STREET 
1003 


53 


1'HIN'TED  BY 
srOTTiSWOObfc  AKH  CO.  LTD.,   XKW-BTllia.l    Mjt'AH;'. 


PEEFA C E 


The  present  volume  is  divided  into  two  parts,  the  first  of  which 
deals  with  Gastric  Carcinoma,  and  the  second  with  the  various 
other  Tumours  which  affect  the  Stomach  and  the  Duodenum. 

The  general  description  of  the  morbid  anatomy  of  the 
malignant  disease  is  based  upon  the  post-mortem  records  of 
3,679  cases  which  we  collected  from  different  sources  ;  while  the 


more  special  phenomena  connected  with  its  pathology  are  derived 
from  an  analysis  of  265  cases  which  were  examined  after  death 
at  the  London  Hospital  and  the  London  Temperance  Hospital. 
With  three  exceptions  the  illustrations  have  been  prepared  for 
us  from  specimens  contained  in  the  museums  of  the  afore- 
mentioned  hospitals  or  in  that  of  the  Royal  College  of  Surgeons. 
The  old  method  of  classifying  gastric  carcinomata  according 
to  their  macroscopical  appearances  has  been  responsible  for 
so  many  erroneous  conclusions  respecting  their  pathology 
and  clinical  aspect  that  we  have  adopted  the  nomenclature 
suggested  by  Drs.  Perry  and  Shaw  in  their  admirable  article 
in  the  Guy's  Hospital  Reports,  and  have  employed  the 
terms  '  scirrhus,' '  medullary  '  and  '  adeno-carcinoma  '  to  indicate 
growths  which  possess  a  definite  histological  structure.  The 
substitution  of  the  microscope  for  the  naked  eye  has  also  had 
the  effect  of  demonstrating  that  the  infectivity  of  a  carcinoma 
of  the  stomach  is  infinitely  more  rapid  and  diffuse  than  the 
presence  of  visible  metastases  has  been  held  to  indicate ;  and 
we  are  convinced  that  much  of  the  non-success  that  has 
attended  the  performance  of  pylorectomy  has  arisen  from  a 
deficient  appreciation  of  the  widespread  nature  of  the  disease. 


vi         CANCEK   AND  TUMOUES  OF  THE   STOMACH 

Since  the  histology  of  the  gastric  complaint  does  not  differ 
materially  from  that  of  carcinoma  of  other  organs  of  the  body, 
we  have  contented  ourselves  with  a  general  sketch  of  the 
subject,  and  for  a  more  detailed  description  would  refer  the 
reader  to  one  of  the  numerous  text-books  on  pathology. 

The  investigations  into  the  etiology  of  gastric  carcinoma 
have  been  conducted  upon  somewhat  different  lines  from  those 
which  custom  has  ordained,  with  the  result  that  many  of  our 
conclusions  differ  materially  from  those  of  previous  writers.  We 
have  endeavoured  to  show  that  the  long-established  teaching 
concerning  the  sex  and  age  incidence  of  the  disease  has  been 
founded  upon  errors  which  alarost  invariably  accrue  from  the 
exclusive  employment  of  hospital  statistics,  and  that  not  only  is 
the  complaint  equally  common  in  the  two  sexes,  but  that  the 
liability  to  it  increases  with  each  decade  of  life  until  about 
eighty  years  of  age.  With  regard  to  the  much-discussed 
question  of  the  increase  of  carcinoma,  it  would  appear  that 
during  the  last  four  years  there  has  been  no  appreciable 
augmentation  of  the  number  of  those  dying  from  the  gastric 
lesion  in  this  country.  For  much  of  the  data  by  which  we  have 
sought  to  establish  these  and  other  kindred  facts  we  are 
indebted  to  Dr.  Tatham,  of  the  General  Register  Office,  who 
has  not  only  afforded  us  a  large  amount  of  special  information, 
but  has  given  us  much  valuable  help  in  the  arrangement  of 
our  own  statistical  material. 

Another  point  of  interest  in  this  connection  is  the  varying 
mortality  from  cancer  of  the.  stomach  in  London  at  different 
periods  of  the  year.  We  had  long  been  aware  that  the  disease 
was  particularly  rife  in  the  wards  of  the  London  Hospital 
during  the  summer  months,  but  until  we  analysed  the  figures 
we  did  not  fully  appreciate  the  fact  that  more  .than  60  per  cent, 
of  the  total  deaths  occurred  between  June  and  November, 
while  the  admissions  to  the  hospital  during  the  winter  months 
only  constituted  about  14  per  cent,  of  the  whole  number  for  the 
year.  Should  further  and  more  extended  inquiries  confirm 
these  conclusions,  much  light  may  possibly  be  thrown  upon, 
the  etiology  of  the  disease. 


PREFACE  vii 

The  symptomatology  has  been  written  from  the  study  of 
154  cases  which  were  treated  and  examined  after  death  at  the 
London  Hospital  and  the  London  Temperance  Hospital.  The 
adoption  of  this  procedure  affords,  we  believe,  a  more  accurate 
idea  of  the  clinical  features  of  the  complaint!  as  it  appears 
in  everyday  practice  than  could  be  obtained  from  the  records 
of  private  experience,  which  are  apt  to  include  an  undue  pro- 
portion of  obscure  or  exceptional  cases.  Each  separate 
symptom  is  considered  in  reference  to  the  condition,  situation, 
and  extent  of  the  morbid  growth,  and  the  conclusions  arrived 
at  have  been  expressed  as  far  as  possible  in  the  form  of  tables, 
so  as  to  prevent  unnecessary  reiteration.  Only  such  cases 
are  quoted  in  full  as  were  deemed  necessary  to  emphasise  some 
fact  of  unusual  interest,  and  all  details  which  were  not  strictly 
relevant  to  the  subject  have  been  omitted.  As  the  work 
has  necessarily  been  written  from  the  standpoint  of  a  physician, 
we  have  merely  sought  to  indicate  the  various  conditions  which 
in  our  experience  seem  to  warrant  or  to  contra-indicate  surgical 
interference,  and  have  left  all  discussions  relative  to  operative 
technique  to  those  who  are  better  qualified  to  deal  with  the 
subject. 

In  the  Second  Part  the  various  Tumours  of  the  Duodenum 
are  considered,  as  well  as  those  of  the  Stomach,  and  special 
attention  is  drawn  to  the  symptoms  and  diagnosis  of  carcinoma 
of  this  portion  of  the  digestive  tract.  Sarcoma  of  the  Stomach, 
although  comparatively  rare,  is  a  subject  of  increasing  impor- 
tance, and  the  success  that  has  attended  the  removal  of  the 
spindle-celled  variety  gives  hope  of  an  ultimate  cure  being 
effected  in  many  of  the  cases.  Gastric  Syphilis  is  another 
disease  which  has  hitherto  attracted  less  attention  than  it 
deserves,  and  there  is  little  doubt  that  a  better  knowledge  of  its 
symptomatology  would  result  in  the  cure  of  many  of  those 
troublesome  cases  of  relapsing  ulcer  or  chronic  gastritis  which 
defy  the  ordinary  methods  of  treatment. 

The  chapters  which  deal  with  Polypi,  Benign  Tumours  and 
Cysts  of  the  Stomach  are  of  the  nature  of  clinical  studies, 
owing  to  the  rarity  of  the  diseases  of  which  they  treat    and 


viii       CANCER   AND   TUMOURS   OF  THE   STOMACH 

the  obscure  nature  of  the  symptoms  and  physical  signs  which 
were  observed  in  the  cases  recorded.  Hair-balls  and  Gastroliths 
are,  strictly  speaking,  tumours  within  rather  than  of  the 
stomach  ;  but  the  fatality  which  has  attended  them  in  the  past, 
owing  to  a  deficient  knowledge  of  their  physical  signs,  has 
induced  us  to  devote  a  special  chapter  to  the  subject  of  Gastric 
Concretions. 

In  conclusion,  we  would  tender  our  grateful  thanks  to  Dr. 
Tatham  for  his  invaluable  help  ;  to  Mr.  C.  H.  Leaf  and  Mr.  L. 
Galsworthy  for  several  drawings  they  kindly  prepared  for  us  ; 
to  Dr.  Murrell  for  some  statistical  facts  relative  to  cancer  of  the 
stomach  at  the  Westminster  Hospital,  and  to  the  Council  of 
the  Royal  College  of  Surgeons,  the  College  Board  of  the  London 
Hospital,  and  the  Board  of  Management  of  the  London  Tem- 
perance Hospital,  for  their  kind  permission  to  utilise  the 
material  contained  in  their  respective  museums. 


29  Hap.let  Street  : 

October  Uth-  1902. 


HISTORICAL    INTRODUCTION 


Cancee  of  the  stomach  has  been  known  from  the  earliest  times, 
but  its  symptoms  were  usually  confused  by  the  ancient  writers 
with  those  of  other  forms  of  abdominal  disease.  Several  instances 
in  which  the  morbid  anatomy  of  the  complaint  was  studied 
appear  in  the  medical  literature  of  the  sixteenth  and  seventeenth 
centuries,  but  no  detailed  description  of  the  disease  was 
attempted  until  after  the  publication  of  a  memoir  upon  the 
subject  by  Morgagni  in  1761. 

The  first  two  decades  of  the  nineteenth  century  witnessed 
a  remarkable  revival  of  pathological  inquiry,  and  an  accurate 
description  of  encephaloid  cancer  was  published  by  Laennec  in 
1812,  which  was  followed  in  1816  by  the  differentiation  of 
colloid  cancer  by  Otto.  A  few  years  later  Cruveilbier  and 
Carswell  published  their  celebrated  works  upon  pathological 
anatomy,  which  included  many  admirable  drawings  of  malignant 
growths  of  the  stomach. 

Until  1851  only  three  varieties  of  the  disease  were  recognised, 
namely,  scirrhus,  encephaloid,  and  colloid  ;  but  in  that  year  the 
microscopical  features  of  the  cylindrical-celled  epithelioma 
were  described  by  Bernhardt,  and  were  subsequently  investi- 
gated more  fully  by  Virchow  and  Forster. 

Since  1770  numerous  treatises  have  been  written  upon  the 
clinical  aspect  of  carcinoma  of  the  stomach,  but  it  was  not 
until  1812  that  an  attempt  was  made,  by  Bayle  and  Cayol,  to 
offer  a  complete  description  of  the  various  symptoms  and  signs 
of  the  disease.  Statistical  inquiries  were  first  instituted  by 
Brinton,  who  carefully  analysed  a  large  series  of  cases  which 


x         CANCEE  AND    TUMOUES  OF  THE   STOMACH 

he  had  collected  from  various  sources,  and  formulated  several 
conclusions  concerning  the  etiology  and  symptomatology  of  the 
complaint,  which  are  of  much  value  even  at  the  present  time. 
The  discoveries  of  Golding  Bird  and  von  den  Velden  concerning 
the  diminished  secretion  of  hydrochloric  acid  in  cancer  of  the 
stomach  gave  a  great  impulse  to  the  chemical  investigation  of 
the  morbid  processes  of  digestion,  and  much  interesting  and 
important  work  in  this  branch  of  diagnosis  has  been  accom- 
plished by  Biegel,  Boas,  Ewald,  and  others. 

The  distinction  between  malignant  and  benign  tumours  of 
the  stomach  was  first  established  by  Andral,  Laennec,  and 
other  great  pathologists  of  the  early  part  of  last  century,  while 
the  differentiation  of  sarcoma  from  carcinoma  is  due  to  the 
labours  of  Virchow.  The  extreme  rarity  of  innocent  growths 
and  the  difficulties  attending  their  diagnosis  formerly  caused 
them  to  be  regarded  as  mere  pathological  curiosities,  but  the 
recent  advance  of  gastric  surgery  has  shown  that  they  possess 
considerable  importance  from  a  clinical  point  of  view.  The 
subject  of  syphilis  of  the  stomach  has  received  very  little 
attention,  although  its  existence  was  recognised  and  its  symp- 
toms and  treatment  carefully  studied  by  Andral  nearly  a  century 
ago ;  and  the  same  remark  applies  to  the  various  concretions 
met  with  in  the  organ,  the  first  example  of  which  was  described 
by  Baudamant  in  1777. 


CONTENTS 


V.\r,v, 
PREFACE         .............  V 

HISTORICAL    INTRODUCTION .  .IX 


PAET  I 

CAECINOMA    OF   THE   STOMACH 

CFIAPTEB 

I.      MORBID   ANATOMY   AND    HISTOLOGY  .......  1 

II.      THE    SEQUELAE    OF    CARCINOMA 33 

III.  ETIOLOGY         ...........  78 

IV.  SYMPTOMATOLOGY 106 

V.      PHYSICAL   SIGNS       ....                         145 

VI.      COMPLICATIONS 177 

VII.      CLINICAL   VARIETIES 194 

VIII.      COURSE,    DURATION,   AND    PROGNOSIS '223 

IX.      DIAGNOSIS         ...........  231 

X.       TREATMENT           ...........  251 

BIBLIOGRAPHY 262 


PAET   II 

TU MOVES   OF   THE   STOMACH  AND  DUODENUM 

I.       SARCOMA   OF   THE    STOMACH 271 

II.       CARCINOMA   AND    SARCOMA   OF   THE    DUODENUM          ....  284 

III.  POLYPI   AND    PEDUNCULATED    TUMOURS    OF   THE    STOMACH  .            .       .  301 

IV.  SYPHILIS   OF    THE    STOMACH     ........  313 

V.       CONCRETIONS    IN    THE    STOMACH             .......  324 

VI.      CYSTS    OF   THE    STOMACH            ........  335 

VII.      BENIGN    TUMOURS 347 


INDEX 


355 


ILLUSTRATIONS 


4. 
5. 

6. 
7. 
8. 
9. 
10. 

11, 
12. 

13. 
14. 

15. 

16. 
17. 

18. 
19. 

20. 
21. 
"2-2. 
23. 


SCIRRHOUS    CARCINOMA    OF    THE    PYLORUS,    CAUSING    STENOSIS     . 

SCIRRHOUS   INFILTRATION    OF    THE    CARDIAC    AND    CENTRAL    PORTION 
OF   THE    STOMACH,   LEAVING   THE    PYLORIC    END   UNAFFECTED. 

SCIRRHOUS    CARCINOMA   OF    THE    PYLORUS,   WITH    ULCERATION    . 

SCIRRHOUS   CARCINOMA   FORMING   A   LOCALISED    TUMOUR 

DIFFUSE  INFILTRATION   OF   THE    STOMACH   BY   SCIRRHOUS    CARCINOMA 

CAULIFLOWER   MASS    OF   SPHEROIDAL-CELLED   CARCINOMA  . 

SOFT    SPHEROIDAL-CELLED    CARCINOMA   OF   THE    CARDIAC    ORIFICE 

ENORMOUS   INFILTRATION    OF   THE    STOMACH   BY   CARCINOMA 

MALIGNANT    ULCER   OF    THE    STOMACH 

INFILTRATION     OF     THE       PYLORUS     BY      SOFT      SPHEROIDAL-CELLED 
CARCINOMA  ......... 

A   LARGE    VILLOUS    GROWTH    OF   THE    LESSER   CURVATURE 

A    CYLINDER-CELLED    CARCINOMA   INVOLVING    THE    GREATER   PART    OF 
THE    STOMACH      


HOUR-GLASS    STOMACH 

A      CYLTNDER-CELLED      CARCINOMA      OF      THE      PYLORUS,      PRODUCING 
STENOSIS 

A   MALIGNANT    ULCER    ENCIRCLING   THE    PYLORUS  , 

COLLOID    CARCINOMA   OF   THE    PYLORUS        . 

COLLOID    CARCINOMA    OF   THE    ENTIRE    STOMACH     . 

COLLOID    CARCINOMA    OF    THE    PYLORUS   INVADING   THE    COLON    . 

EPITHELIOMA     OF     THE      ESOPHAGUS,    WITH    A    SECONDARY     GROWTH 
IN    THE    STOMACH    

SECTION    OF   A    SCIRRHOUS    CARCINOMA   OF    THE    STOMACH  . 

SECTION    OF   A    SCIRRHOUS    CARCINOMA   OF   THE    STOMACH 

SECTION    OF    A    CYLINDER-CELLED  CARCINOMA    OF    THE    STOMACH 

SCIRRHOUS     CARCINOMA     OF     THE      CARDIAC      ORIFICE,     WITH     HOUR 
GLASS    STOMACH 

24.       DIAGRAM    OF    THE    BLOOD-SUPPLY    OF    THE    STOMACH    AND     DUODENUM 


5 

6 
7 
8 
9 
10 
11 

12 
10 

14 
15 

16 
17 
18 
18 

19 

26 

;jo 
;;i 

31 

o9 
43 


xiv       CANCEE  AND   TUMOUES   OF  THE   STOMACH 


FI(i. 

25. 

26. 

27. 
28. 
29. 
30. 
81. 
32. 
33. 
34. 
35. 

36. 

37.) 
38.) 
39. 
4\ 

41. 

2. 

43. 

44. 

45. 

46.) 

47.) 

48. 
49. 
50. 
51. 
52. 
53. 

54. 
55. 
56. 


A     MEDULLARY     GROWTH     WHICH     HAD      SLOUGHED     AND     PRODUCED 
PERFORATION    OF    THE    STOMACH 

A     CYLINDER-CELLED     GROWTH     OF     THE     PYLORUS     INVADING     THE 
DUODENUM  ......... 

A   GROWTH    OF   THE   CARDIA   EXTENDING   INTO    THE    OESOPHAGUS     . 

DIAGRAM    OF   THE    LYMPHATICS    OF    THE    STOMACH 

DIAGRAM    OF   THE    THORACIC    DUCT   AND   ITS    TRIBUTARIES      . 

CHART    SHOWING   A   SUBNORMAL   TEMPERATURE    IN    CARCINOMA  . 

CHART    SHOWING   OCCASIONAL   ATTACKS    OF   FEVER 

CHART    SHOWING    CONTINUED    FEVER  .  .  .  . 

CHART    OF   SEPTICEMIA   IN    CANCER   OF   THE    STOMACH  . 

CHART    OF   PNEUMONIA   IN   CANCER   OF    THE    STOMACH 

DRAWING   OF  A  SMALL   MASS    OF   CANCEROUS   TISSUE    EXPELLED   FROM 
THE    STOMACH  . 

FRAGMENTS    OF    GASTRIC    MUCOSA   OBTAINED    BY    CURETTAGE 
CELLS    SHOWING   ATYPICAL    MITOSES 

DIAGRAM   OF   THE    SITUATION    OF   THE    NORMAL    STOMACH   , 

DIAGRAM      OF      THE      MOVEMENT      OF     A     GASTRIC      TUMOUR     WITH 
RESPIRATION 


DIAGRAM    OF   A   MOVABLE    PYLORIC    TUMOUR         .... 

DIAGRAM    OF   A   TUMOUR   OF    THE   ANTERIOR   WALL    OF   THE    STOMACH 

DIAGRAM  OF  THE  MOVEMENT  OF  A  PYLORIC  TUMOUR  UPON 
INFLATION    OF    THE    STOMACH  ...... 

DIAGRAM      OF      THE      DOWNWARD      DISPLACEMENT      OF      A     PYLORIC 
TUMOUR       .......... 

DIAGRAM    OF   TUMOURS    MET    WITH    IN    CARCINOMA   OF    THE    FUNDUS 

DIAGRAMS  OF  THE  TUMOURS  MET  WITH  IN  CANCEROUS  INFILTRATION 
OF    THE    ENTIRE    STOMACH  .  .  .  .  ... 

CARCINOMA    OF    THE    CARDIAC    ORIFICE    OF    THE    STOMACH 

CARCINOMA    OF    THE    BODY    OF   THE    STOMACH      .... 

CARCINOMA    OF    THE    ENTIRE    STOMACH 

CARCINOMA    OF   THE    PYLORUS 

SCIRRHOUS    CARCINOMA   OF   THE    ENTIRE    STOMACH 

DRAWING  OF  THE  POSTERIOR  WALL  OF  THE  STOMACH,  SHOWING  A 
PROJECTION  OF  THE  PANCREAS  THROUGH  THE  BASE  OF  A 
CHRONIC    ULCER.  ......... 

SECTION    OF    SARCOMA    OF    THE    STOMACH 

SPINDLE-CELLED    SARCOMA   OF    THE    STOMACH 

SECONDARY   GROWTH    OF    MELANOTIC    SARCOMA    IN    THE    STOMACH  .       . 


46 

58 

59 

62 

64 

135 

136 

136 

137 

138 

158 
159 

161 

165 

16S 
169 
169 

170 

172 
173 

174 
195 
197 
198 
200 
202 

243 
272 
273 

275 


ILLUSTEATIONS  XV 

i.i,:.  v.m-.k 

57.  CARCINOMA    OF    THE    DUODENUM 285 

58.  DIAGRAM   OF    THE     PHYSICAL     SIGNS     OF     CARCINOMA     OF     THE    FIRST 

PART    OF   THE    DUODENUM         ........       289 

59.)    PHYSICAL     SIGNS     AND     POST-MORTEM     APPEARANCES     IN     A     CASE    OF 

GO.  f  CARCINOMA   OF    THE    THIRD    PART    OF   THE    DUODENUM  .  .      295 

61.      MUCOUS    POLYPI   IN    THE    STOMACH  .......      302 

62.) 

63.  f 

64.  A   HAIR-BALL    REMOVED    FROM    THE    STOMACH  .....      325 

I   DIAGRAMS    OF    TUMOURS    FORMED    BY    A    HAIR-BALL    IN    THE    STOMACH       328 

66.  J 

67.  LARGE    CYST    OF    THE    STOMACH 341 

68  ) 

*  !-    PAPILLOMA    OF   THE    PYLORUS  348,  349 

69.1 

70.      LIPOMA   OF   THE    STOMACH      .........      350 


PEDUNCULATED    FIBROMATA    OF    THE    STOMACH  ....       305,    306 


PAET  I 
CARCINOMA    OF   THE   STOMACH 

CHAPTEE  I 

MORBID  ANATOMY  AND   HISTOLOGY 

Tumours  of  the  stomach  may  be  classified  as  benign  and 
malignant.  The  former  are  comparatively  rare,  and  most  of 
them  are  merely  pathological  curiosities.  The  latter  constitute 
nearly  94  per  cent,  of  all  the  tumours  of  the  viscus  met 
with  on  the  post-mortem  table,  and  more  than  98  per  cent,  of 
those  which  can  be  detected  during  life.  It  is  therefore  advis- 
able to  consider,  in  the  first  place,  those  neoplasms  which  from 
their  extensive  growth  and  destructive  character  must  be  re- 
garded as  diseases  of  primary  importance,  and  subsequently 
those  which  are  either  devoid  of  clinical  interest,  or  at  most  are 
productive  of  symptoms  of  an  obscure  nature  and  of  irregular 
occurrence. 

It  is  usually  the  custom  to  describe  a  malignant  tumour  of 
the  stomach  as  a  '  carcinoma,'  or  '  cancer,'  more  or  less  qualified 
by  terms  which  indicate  some  special  physical  feature  of  the 
growth.  Of  late  years,  however,  the  opinion  has  been  steadily 
gaining  ground  that  many  cases  which  are  regarded  as  examples 
of  carcinoma  are  really  sarcomatous  in  character,  and  at  the 
present  time  there  is  sufficient  evidence  in  favour  of  this  view 
to  warrant  the  inclusion  of  sarcoma  as  a  special  and  important 
variety  of  malignant  disease  of  the  organ.  Inasmuch  as  the 
duodenum  is  practically  a  prolongation  of  the  stomach,  the 
special  features  of  carcinoma  of  this  portion  of  the  digestive 
canal  also  demand  consideration. 

Primary  Carcinoma 

The  neoplasms  which  belong  to  this  group  originate  in 
the  epithelial  and  glandular  structures  of  the  organ,  and  have 

B 


2  CANCER   OF   THE   STOMACH 

been  variously  described  at  different  times.  By  the  earlier 
writers  they  were  classified  according  to  their  general  features 
as  hard  and  soft  cancers,  villous  and  fungoid  growths,  or  can- 
cerous ulcers ;  while  at  a  somewhat  later  date  certain  special 
varieties  were  recognised  by  the  terms  'scirrhus,'  'encephaloid,' 
'  villous,'  and  '  colloid.'  This  nomenclature,  while  it  expresses 
more  or  less  succinctly  the  naked-eye  appearances  of  the  princi- 
pal forms  of  the  disease,  affords  but  little  clue  to  their  morpho- 
logy, and  it  has  therefore  become  necessary  to  classify  them 
according  to  their  histological  structure.  By  means  of  the 
microscope  three  types  of  primary  cancer  of  the  stomach  may 
be  recognised.  In  the  first  of  these  the  cellular  elements  are 
similar  in  shape  and  size  to  the  cells  which  normally  line  the 
gastric  tubules,  and  it  has  consequently  received  the  name  of 
'glandular'  or  '  spheroidal-  cell '  carcinoma.  Inasmuch,  how- 
ever, as  both  the  macroscopic  and  microscopic  features  of  the 
growth  vary  according  to  the  amount  of  fibrous  tissue  it  con- 
tains, it  is  convenient  to  distinguish  a  hard  variety  (scirrhus) 
from  a  soft  form  (medullary) .  In  the  second  type  the  tubular 
and  hollow  spaces  in  the  matrix  are  lined  by  columnar  cells 
like  those  which  exist  in  the  pyloric  glands,  and  to  this  the 
term  '  cylindrical-celled  carcinoma  :  or  '  adenocarcinoma  '  is  ap- 
plied. Lastly,  each  variety  may  undergo  myxomatous  degene- 
ration, which  affects  both  the  cells  and  fibrous  stroma,  and 
transforms  the  tumour  either  wholly  or  in  part  into  a  firm 
gelatinous  mass  termed  '  colloid  carcinoma.' 

These  different  varieties  are  not  always  sharply  distinguished 
from  each  other,  but  are  apt  to  present  many  gradations  and 
transitional  forms.  Thus,  a  soft  spheroidal-celled  growth  may 
possess  a  hard  fibrous  base,  or  a  typical  scirrhus  may  be 
covered  with  fungoid  outgrowths  ;  while  in  rarer  cases  the 
neoplasm  may  exhibit  a  cylindrical-cell  formation  at  one  spot 
and  a  spheroidal-cell  structure  at  another. 

Primary  Carcinoma  of  the  Stomach 

c  ,        --it      „  'Hard  (Scirrhus). 

bpheroidal-cell     .     -  ...   „     .>_  _   „  _,         ,    ,  ... 

(bolt  (Medullary  or  Encephaloid). 

Cylindrical-cell  (Adenocarcinoma) . 

Colloid. 

1.  Scirrhus  (Hard  Spheroidal-celled  Carcinoma). — This 
variety  is  chiefly  met  with  in  the  pyloric  region  of  the  stomach 


MOEBID  ANATOMY  AND  HISTOLOGY  3 

and  is  characterised  by  its  firm  structure  and  its  tendency  to 
contraction. 

(a)  It  usually  commences  immediately  inside  the  orifice, 
which  it  often  encircles,  and  thence  spreads  into  the  con- 
tiguous gastric  tissues.  The  pylorus  is  thus  converted  into  a 
rounded  or  oval  mass,  the  surface  of  which  is  smooth  or  slightly 
lobulated.  When  laid  open  the  diseased  portion  of  the  viscus 
presents  a  conical  or  funnel  shape,  while  the  opening  into  the 
duodenum  is  converted  into  a  long,  narrow,  and  often  tortuous 
channel,  which  may  only  admit  the  passage  of  a  probe. 


Fig.  1. — Scirrhous  carcinoma  of  the  pylorus  causing  stenosis. 
(London  Hospital  Museum.) 


The  disease  is  usually  limited  to  the  stomach,  and  seldom 
invades  the  first  part  of  the  duodenum ;  but  in  the  opposite 
direction  it  shades  off  gradually  in  the  gastric  wall,  and  is  often 
prolonged,  in  the  form  of  bands  or  rows  of  small  nodules,  for 
some  distance  along  one  or  both  curvatures.  Examination  of 
the  surface  of  the  section  shows  that  the  various  coats,  though 
firmly  welded  together,  can  still  be  distinguished  from  one 
another.  From  one-half  to  two-thirds  of  the  mass  consists  of 
submucous  tissue  which  exhibits  a  smooth  white  glistening 
structure,  slightly  concave  at  its  centre  owing  to  contraction 
of  its  fibrous  elements,  and  so  hard  as  to  creak  under  the  knife. 
The  contractile  tissue  of   the    muscular  coat  is  much  hyper- 

13  2 


4  CANCEE  OF  THE   STOMACH 

trophied,  and  appears  as  a  brownish  red  or  pale  pink  senii- 
translucent  material,  enclosed  in  small  polygonal  meshes  of  a 
pearly  white  colour.  The  walls  of  these  meshes  are  thickest 
where  they  run  perpendicularly  to  the  plane  of  the  mucous 
membrane,  and  at  first  correspond  to  the  lines  of  connective 
tissue  which  normally  intersect  the  muscular  coat ;  but  as  the 
disease  progresses  the  infiltration  becomes  more  diffuse  and 
the  reticulation  more  complex.    The  subserous  tissue  is  thickened 


Fig.  2. — Scirrhous  infiltration  of  the  cardiac  and  central  portions  of  the  stomach, 
leaving  the  pyloric  end  unaffected.     (London  Hospital  Museum.) 

and  opaque,  and  the  peritoneum  itself  is  usually  covered  with 
organised  lymph,  in  which  small  nodules  of  new  growth  may 
sometimes  be  detected.  The  mucous  membrane  is  either 
congested  in  patches,  or  exhibits  a  uniform  dead-white  colour, 
while  its  surface  may  be  slightly  uneven  as  a  result  of  chronic 
inflammation,  or  be  covered  with  small  nodules  of  new  growth. 
In  a  large  proportion  of  the  cases  some  degree  of  ulceration  is 
present,  the  ulcers   being  small  and  superficial  in  character, 


MOEBID  ANATOMY  AND  HISTOLOGY  5 

with   ill-defined  sloping  edges    and  bases  which  are    smooth, 
irregular,  papillomatous,  or  ragged. 

(b)  Occasionally  scirrhous  carcinoma  is  strictly  limited  to 
the  pylorus,  where  it  forms  a  tumour  that  may  attain  the  size 
of  a  Tangerine  orange.  The  line  of  demarcation  between  the 
healthy  and  diseased  tissues  is  fairly  defined,  and  with  the 
exception  of  a  slight  extension  along  one  or  both  curvatures 
the  walls  of  the  viscus  around  the  tumour  are  practically 
free  from  infiltration.  The  greater  part  of  the  mass  is  com- 
posed of  dense  white  fibrous  tissue,  streaked  or  flaked  with 
yellow ;    but   not   infrequently  it  contains  one  or   two    small 


Fig.  3. — Scirrhous  carcinoma  of  the  pylorus  with  ulceration. 
(Museum  of  the  Royal  College  of  Surgeons.) 


cysts  filled  with  a  grumous  fluid,  or  presents  signs  of  colloid 
degeneration.  As  a  rule  the  pyloric  orifice  is  greatly  con-, 
tracted  and  is  converted  into  a  narrow  tortuous  channel ;  but 
when  ulceration  has  taken  place  the  interior  of  the  tumour 
may  present  a  large  sloughing  cavity,  which  communicates 
freely  with  both  the  stomach  and  the  duodenum. 

(c)  In  a  third  variety  the  disease  takes  the  form  of  a 
localised  induration  of  the  gastric  wall  close  to  the  pylorus. 
The  edges  of  the  growth  are  slightly  elevated  above  the 
surrounding  mucous  membrane,  while  its  centre  is  somewhat 
depressed.  The  surface  is  usually  smooth  and  covered  with 
a  brownish  mucoid  secretion  ;  but  occasionally  it  has  a  furrowred 


6  CANCEE  OF  THE   STOMACH 

or  terraced  appearance,  as  though  its  substance  had  constantly 
scaled  off.  The  peritoneal  aspect  is  thickened  and  often  ad- 
herent to  the  liver  or  pancreas,  and  on  section  the  whole  growth 
seems  to  consist  entirely  of  fibrous  tissue,  which  yields  a  little 
white  juice  when  scraped.  Owing  to  its  proximity  to  the 
pylorus,  it  not  infrequently  displaces  and  contracts  the  orifice, 
and  thus  occasions  considerable  dilatation  of  the  stomach.  It 
will  be  observed  that  in  its  general  characters  this  form  of 
cancer  closely  resembles  the  scar  of  a  simple  chronic  ulcer  ;  and 
there  can  be  little  doubt,  as  Dittrich  originally  suggested,  that 


Fig.  4. — Scirrhous  carcinoma  forming  a  localised  tumour  at  the  pylorus. 
Natural  size.     (London  Hospital  Museum.) 


in  the  absence  of  secondary  deposits  in  the  liver  the  malignant 
nature  of  the  disease  is  very  apt  to  be  overlooked. 

(d)  Scirrhus  may  invade  the  whole  of  the  stomach  and  con- 
vert it  into  a  small  thick- walled  sac,  which  has  been  likened  to  a 
leather  bottle.  In  a  characteristic  case  the  organ  is  found  after 
death  to  be  retracted  beneath  the  left  lobe  of  the  liver,  while 
the  space  it  usually  occupies  is  filled  by  the  transverse  colon. 
When  isolated  it  appears  like  a  piece  of  thick  indiarubber  tubing 
from  four  to  six  inches  in  length,  and  with  a  diameter  often  less 
than  that  of  the  small  intestine.  The  lower  end  of  the  oeso- 
phagus may  be  slightly  dilated,  and  the  finger  can  easily  be  passed 


MOEBID  ANATOMY  AND  HISTOLOGY  7 

through  the  cardiac  orifice.  The  pylorus,  on  the  other  hand,  may 
be  so  contracted  as  barely  to  admit  the  tip  of  the  little  ringer. 
When  the  viscus  is  laid  open,  its  walls  are  found  to  be  greatly 
thickened,  tough  and  incollapsible,  especially  in  the  pyloric  and 
central  portions,  the  induration,  which  chiefly  affects  the 
submucous  and  muscular  coats,  gradually  diminishing  towards 
the  fundus.  Its  cavity  is  represented  by  a  small  hollow  at 
either  end  of  the  tubular  mass,  which  communicate  by  a  narrow 


Fig.  5. — A  stomach  viewed  from  behind,  showing  diffuse  infiltration  by  scirrhous 
carcinoma,  with  enlarged  glands  along  the  curvatures.  (Museum  of  the  Royal 
College  of  Surgeons.) 


channel,  the  cubic  capacity  of  the  whole  varying  from  half  an 
ounce  to  three  fluid  ounces.  The  inner  surface  is  sometimes  quite 
smooth,  and  covered  with  a  layer  of  tenacious  mucus  ;  but  as  a 
rule  one  or  more  small  superficial  ulcers  may  be  observed  about 
the  centre  of  the  organ,  while  in  rare  instances  the  whole  of 
the  mucous  membrane  is  extensively  ulcerated.  The  peritoneal 
investment  is  much  thickened,  and  there  are  usually  numerous 
firm    adhesions    between    the    diseased    organ    and   the   liver, 


- 


CANCER   OF  THE   STOMACH 


diaphragm,  and  colon.  Occasionally  signs  of  recent  peritonitis 
are  present  in  the  upper  segment  of  the  abdomen.  In  rare 
instances  diffuse  scirrhus  of  the  stomach  is  associated  either 
with  stenosis  of  the  cardiac  orifice  from  implication  of  the 
lower  end  of  the  oesophagus,  or  with  an  annular  growth  at  the 
centre  of  the  organ,  which  divides  it  into  two  small  thick-walled 
pouches,  each  about  the  size  of  a  walnut. 


Fig.  6.—  Cauliflower  mass  of  spheroidal-celled  carcincma  situated  near  the  pylorus 
and  extending  along  the  lesser  curvature.     (London  Hospital  Museum.) 


2.  Medullary  Carcinoma  (Soft  Spheroidal-celled  Cancer). — 

This  variety  of  the  disease  is  characterised  by  an  exuberant 
soft  growth,  which  infiltrates  all  the  coats  of  the  stomach  and 
is  usually  attended  by  extensive  ulceration.  As  a  rule  it 
commences  in  the  pyloric  half  of  the  organ,  near  the  lesser 


MOEBID  ANATOMY  AND  HISTOLOGY 


9 


curvature,  where  it  forms  either  an  irregular  flattened  tumour, 
which  is  slightly  raised  above  the  adjacent  mucous  mem- 
brane, or  a  large  cauliflower  mass  surrounded  by  several 
smaller  tumours  or  dendritic  growths.  The  tissue  of  which  it 
is  composed  is  of  soft  consistence,  dead- white,  greyish  white,  or 
pale  pink  in  colour,  and  yields  an  abundant  milky  juice  when 
scraped  with  a  knife.     Owing  to  its  general  resemblance  to 


Fig.  7.— Soft  ulcerating  growth  of  spheroidal-celled  carcinoma  situated  at 
the  cardiac  orifice  and  spreading  into  the  oesophagus.  (London  Hospital 
Museum.) 


brain  substance,   this  variety  of  cancer  was  formerly  termed 
'  encephaloid.' 

(a)  The  disease  may  be  strictly  circumscribed  and  occupy 
a  surface  several  inches  square,  or  it  may  be  elongated 
and  extend  for  some  distance  in  the  long  axis  of  the  organ  ; 
while  occasionally  the  whole  of  the  inner  surface  of  the 
stomach  is  covered  with  a  cauliflower  growth,  which  almost 
obliterates  the  cavity  and  encroaches  some  distance  upon  the 
oesophagus. 


10 


CANCER  OF  THE   STOMACH 


After  the  tumour  has  attained  a  certain  stage  of  develop- 
ment it  is  prone  to  undergo  degenerative  changes,  which 
greatly  alter  its  appearance.  In  most  cases  interstitial  haemor- 
rhages take  place,  which  give  a  section  a  mottled  red  or  yellow 
colour,  and  its  superficial  aspect  a  brownish-black  tint.  In  other 
instances  the  cellular  elements  are  affected  by  fatty  and  mole- 
cular changes,  which  produce  softening  of  the  tissue  and  disin- 
tegration of  the  tumour.  Both  conditions  tend  to  reduce  the 
bulk  of  the  growth  and  to  produce  ulceration,  so  that  at  a 
necropsy  it  is  rare   to    find   the   fungating   mass   intact.     On 


Fig.  8. — Stomach  viewed  from  behind,  showing  enormous  infiltration  of  its  walls 
with  soft  spheroidal-celled  carcinoma,  and  its  cavity  almost  obliterated  by  a 
cauliflower  growth.     (London  Hospital  Museum.) 


the  contrary,  there  usually  exists  a  bowl-shaped  or  crater-like 
depression  in  the  centre  of  the  tumour,  the  edges  of  which  are 
elevated,  irregular,  and  somewhat  overhanging ;  the  sides 
ragged,  sloughy,  or  fungating ;  while  the  base  varies  according 
as  it  is  formed  by  tumour  substance  or  by  the  smooth  muscular 
or  peritoneal  coat  of  the  stomach.  When  two  or  more  ulcers 
are  present,  they  may  coalesce  and  form  one  deep  cavity  with  a 
serpiginous  overhanging  edge. 

(b)  It  sometimes  happens  that  the   entire  growth  sloughs 
away,  and  merely  leaves  an  ulcerated  condition  of  the  mucous 


MOEBID  ANATOMY  AND  HISTOLOGY 


11 


membrane  to  mark  its  former  site.  Such  an  ulcer  usually 
presents  elevated,  irregular,  and  everted  edges,  and  a  ragged  or 
papillomatous  base  ;  but  occasionally  it  undergoes  a  further 
retrograde  change,  whereby  the  edges  become  hard,  smooth,  and 
sloping,  and  the  base  clean  and  fibrous  in  appearance.  In  this 
way  a  soft  medullary  excrescence  ultimately  gives  place  to  an 
ulcer  which  closely  resembles  a  primary  scirrhus,  and  may  even 
undergo  partial  cicatrisation.  This  structural  metamorphosis 
has  been  described  as  '  spontaneous  healing  of  cancer  ;  '  but  the 


Fig.  9. — Malignant  ulcer  of  the  stomach.     (Museum  of  the  Royal 
College  of  Surgeons.) 


expression  is  a  delusive  one,  since  even  in  those  rare  cases 
where  the  ulcer  heals  superficially  active  growth  still  continues 
in  the  base  of  the  disease,  and  ultimately  leads  to  secondary 
deposits  in  the  lymphatic  glands  and  other  neighbouring 
tissues. 

(c)  Medullary  carcinoma  also  occurs  in  the  form  of  a  diffuse 
infiltration  of  the  walls  of  the  stomach,  which  may  either  affect 
the  greater  part  of  the  organ  or  be  limited  to  its  pyloric  half. 
In  this  condition  the   submucous  tissue  is  greatly  thickened, 


12 


CANCEK  OF  THE   STOMACH 


and  the  mucous  membrane  is  thrown  into  firm  folds  that  look 
like  hypertrophied  rugae,  or  presents  numerous  thick  wheals 
which  run  parallel  to  the  long  axis  of  the  viscus.  Here  and 
there  superficial  ulcers  with  ragged  walls  and  fungating  bases 
may  be  observed,  or  the  surface  may  be  studded  with  nodules, 
some  of  which  exhibit  deep    sloughing   cavities.     Where  the 


Fig.  10.  —  Enormous  infiltration  of  the  pyloric  half  of  the  stomach  by  soft 
spheroidal-cell  carcinoma,  with  ulcerating  nodules  upon  the  inner  surface. 
(London  Hospital  Museum.) 


disease  is  most  advanced  the  muscular  coat  is  also  infiltrated 
and  its  contractile  tissue  destroyed ;  but  elsewhere,  and 
especially  in  the  neighbourhood  of  the  fundus,  it  is  often 
thickened  from  hypertrophy.  The  peritoneum  is  condensed 
and  opaque,  and  is  not  infrequently  studded  with  numerous 
nodules  of  new  growth. 


MOEBID  ANATOMY  AND   HISTOLOGY 


13 


3.     Adenocarcinoma    (Cylindrical-celled    Carcinoma). — 

This  variety  may  occur  in   any  part  of  the  stomach,   but  is 
most  common  in  the  pyloric  region. 

(a)  It  usually  presents  itself  in  the  form  of  a  soft  red  fungoid 
tumour,  which  springs  from  a  broad  base  and  is  sometimes 
studded  with  delicate  papilla3  that  give  it  a  distinctly  villous 
character.  It  usually  possesses  a  firmer  consistence  than  a 
medullary  growth.  On  section  it  yields  a  milky  juice,  and 
appears  to  have  grown  by  spreading  itself  over  the  surface  of 
the  stomach  rather  than  by  infiltrating  the  deeper  layers. 


Fig.  11. — Carcinomatous  infiltration  of  the  stomach,  with  a  large  villous  growth 
projecting  from  the  lesser  curvature.  Viewed  from  behind.  (Museum  of  the 
Eoyal  College  of  Surgeons.) 


Owing  to  its  remarkable  vascularity,  small  haemorrhages  are 
very  prone  to  occur  in  its  substance  and  to  give  the  section  a 
variegated  red  and  brown  appearance.  The  more  extensive 
extravasations  of  blood  are  usually  followed  by  sloughing  of 
portions  of  the  tumour  and  the  production  of  deep  ulcers, 
whose  cavities  are  partially  filled  by  fungoid  outgrowths. 
Finally  the  entire  mass  may  become  gangrenous,  and  being 
detached  may  leave  an  irregular  area  of  ulceration  surrounded 
by  a  reel  projecting  fungus-like  wall.  If  the  necrotic  process 
involves  the  deeper  coats  of  the  stomach,  perforation  may  ensue, 


14 


CANCEE  OP  THE   STOMACH 


but  the  aperture  is  often  difficult  to  detect  amid  the  proliferat- 
ing tissue  which  composes  the  base  of  the  sore. 

(b)  Occasionally  the  disease  forms  a  girdle  round  the  stomach 
in  the  pyloric  or  central  region,  in  the  same  manner  that  it 
encircles  the  large  intestine.  In  such  cases  the  only  external 
evidence  of  the  neoplasm  may  consist  of  a  shallow  and  opaque 


Fig.  12. — An  enormous  ulcerated  fungoid  growth  of  cylinder-celled  carcinoma  in- 
volving the  greater  part  of  the  stomach  and  extending  into  the  oesophagus. 
(Museum  of  the  London  Temperance  Hospital.) 


sulcus,  which  traverses  the  viscus  at  right  angles  to  its  long 
axis  ;  while  internally  the  growth  appears  as  a  red  fungating 
ring  that  divides  the  stomach  into  two  sacs  of  unequal 
size.  If  the  constriction  occurs  close  to  the  pylorus,  the  general 
appearance  of  the  stomach  is  similar  to  that  met  with  in 
stenosis  of  the  orifice  (fig.  13). 

(c)  Like  the  preceding  varieties,  adenocarcinoma  sometimes 


MOEBID  ANATOMY  AND  HISTOLOGY 


15 


occurs  as  an  infiltration  of  the  walls  of  the  organ,  which  com- 
mences near  the  pylorus  and  involves  the  greater  portion  of 
the  viscus.  In  this  condition  the  pylorus  is  usually  thickened 
and  rigid,  and  its  orifice  patent  rather  than  contracted.  The 
surface  of  the  mucous  membrane  is  uneven  or  distinctly 
nodular,  and  is  often  superficially  ulcerated.     When  the  entire 


Fig.  13. — A  cylindrical-celled  growth  at  the  centre  of  the  stomach,  dividing  the 
organ  into  two  sacs.     (London  Hospital  Museum.) 


stomach  is  infiltrated  its  tissues  are  greatly  thickened,  but  its 
cavity  is  seldom  reduced  to  the  same  extent  as  in  diffuse 
scirrhus. 

4.  Colloid  Carcinoma  (Mucous  or  Gum  Cancer).— Each 
variety  of  carcinoma  is  liable  to  undergo  a  structural  metamor- 
phosis, whereby  both  its  epithelial  cells  and  connective  tissue  are 
converted  into  a  gelatinous  gum-like  material  termed  '  colloid.' 


16 


CANCEB  OF  THE   STOMACH 


This  change  may  either  occur  after  the  growth  has  already- 
existed  for  some  time,  and  only  partially  affect  the  bulk  of  the 
tumour,  or  it  may  ensue  almost  simultaneously  with  the  differen- 
tiation of  the  new  elements,  so  that  even  the  growing  edge 
presents  a  gelatinous  appearance.  These  facts  help  to  explain 
the  variations  that  occur  in  the  naked-eye  appearances  of  the 
disease  in  different  cases. 

(a)  When  the  original  growth  has  been  more  or  less  circum- 
scribed, colloid  carcinoma  appears  as  a  nodular  mass  of  light 


Fig.  14.— Cylinder-celled  carcinoma  of  the  pylorus,  giving  rise  to  stenosis  of  the 
orifice.     Viewed  from  behind.     (Museum  of  the  Eoyal  College  of  Surgeons.) 


brown  colour  and  slimy  consistence,  which  projects  into  the 
cavity  of  the  stomach.  The  surface  of  the  tumour  is  usually 
ulcerated,  and  the  deeper  tissues  which  are  thereby  exposed  to 
view  exhibit  a  honeycombed  structure,  the  meshes  of  which 
are  filled  with  granules  of  gelatinous  substance.  The  base  of 
the  ulcer  may  consist  of  one  of  the  coats  of  the  stomach  in 
a  comparatively  healthy  state,  or  of  hard  scirrhous  material ; 
while,  if  the  transformation  has  been  more  complete,  nodules  of 
colloid  may  be  observed  beneath  the  serous  coat.     In  cases  of 


MOEBID  ANATOMY  AND  HISTOLOGY 


17 


medullary  or  adeno-carcinoma,  where  the  greater  part  of  the 
tumour  has  sloughed  off,  leaving  an  area  of  ulceration,  the 
colloid  change  may  be  recognised  by  the  presence  of  translucent 
granules,  which  project  from  the  walls  and  everted  edges  of  the 
ulcer  (fig.  15). 

(b)  More  commonly  colloid   takes   the  form   of   a  diffuse 
infiltration,  which  involves  the  greater  part  of  the  stomach,  and 


Fig.  15. — A  malignant  ulcer  (spheroidal-cell)  encircling  the  pylorus,  which  has 
undergone  partial  colloid  degeneration.    (London  Hospital  Museum.) 


not  infrequently  spreads  by  direct  continuity  into  the  duodenum 
and  oesophagus.  In  this  condition  the  organ  is  somewhat 
contracted  and  its  walls  greatly  thickened.  The  external 
surface  is  profusely  studded  with  nodules,  which  vary  in  size 
from  a  millet-seed  to  a  cobnut,  and  is  more  or  less  adherent 
to  the  large  omentum  and  the  surrounding  viscera.  On  section 
the  different  coats  appear  to  be  replaced  by  a  light-coloured 
fibrillar  network,  which   encloses  a  quantity    of    transparent 

The  inner  surface  is 
c 


colourless  or  brown  gelatinous  material 


18 


CANCEE  OF  THE   STOMACH 


Ftg.  16. — A  stomach,  viewed  from  behind,  showing  colloid  carcinoma  of  the  pylorus. 
(Museum  of  the  Eoyal  College  of  Surgeons.) 


Fig.  17. —  Colloid  infiltration  of  the  entire  stomach.     (Museum  of  the  Royal 
College  of  Surgeons.) 


MOEBID  ANATOMY  AND  HISTOLOGY 


19 


usually  nodular,  and  is  often  extensively,  though  superficially, 
ulcerated.  The  extreme  fundus  sometimes  escapes  when  the 
rest  of  the  organ  is  involved. 

This  diffuse  form  is  very  apt  to  invade  the  peritoneum,  and 
transform  the  omentum  into  an  oblong  thick  mass  profusely 
studded  with  colloid  granules.  The  gastro-hepatic  omentum 
is  affected  in  a  similar  manner,  and  occasionally  the  disease 
spreads  into  the  substance  of  the  liver  or  pancreas.  In  other 
cases  the  general  surface  of  the  peritoneum  becomes  covered 
with  colloid  tumours  of  various  sizes,  which  unite  the  intestines 
together,  and  may  even  completely  fill  the  abdominal  cavity. 


Fig.  18. — Colloid  carcinoma  of  the  pylorus  invading  the  transverse  colon.     Speci- 
men viewed  from  behind.     (Museum  of  the  Royal  College  of  Surgeons.) 


This  form  of  carcinoma  rarely  gives  rise  either  to  haemorrhage 
or  to  perforation  of  the  stomach. 

The  relative  frequency  of  the  different  Carcinomata. — Out 

of  180  cases  collected  by  Brinton,  130,  or  72  per  cent.,  were 
scirrhus,  thirty-two,  or  18  per  cent.,  medullary,  and  seventeen,  or 
9*4  per  cent.,  colloid  ;  and  upon  the  authority  of  these  figures  it 
has  ever  since  been  taught  that  '  scirrhus  is  found  in  three- 
quarters  of  the  cases  of  cancer  of  the  stomach.'  This  statement 
is  not  only  quite  erroneous,  but  is  so  obviously  based  upon 
insufficient  evidence  that  it  seems  almost  incredible  it  could 
have  remained  unchallenged  for  such  a  length  of  time.     In  the 

c  2 


20  CANCER  OF  THE   STOMACH 

first  place,  it  will  be  observed  that  the  number  of  cases  is  far 
too  small  to  warrant  any  definite  conclusion  being  drawn  from 
them  ;  while  the  method  of  collecting  isolated  examples  from 
various  sources  is  open  to  the  serious  objection  that  it  is  only 
exceptional  cases  of  a  disease  that  are  usually  deemed  worthy 
of  publication.  But,  in  addition  to  these  initial  sources  of 
error,  the  growths  themselves  were  classified  solely  by  their 
physical  characters,  the  hard  varieties  being  termed  '  scirrhus,' 
and  the  soft  'medullary,'  whereas  it  is  now  accepted  that  not 
only  is  it  often  impossible  to  determine  the  nature  of  the 
cancer  by  the  naked  eye,  but  even  the  microscope  inay  fail  to 
differentiate  between  the  two  varieties  of  the  spheroidal-celled 
growth.  Finally,  Brinton  appears  to  have  been  unaware  of  the 
existence  of  the  cylindrical-celled  carcinoma,  which,  according 
to  Cornil  and  Ranvier,  is  the  commonest  of  all ;  so  that  we  must 
conclude  that  the  cases  of  this  description  which  occurred  in 
his  series  were  classified  as  scirrhus  or  medullary,  according 
as  the  disease  took  the  form  of  an  infiltration  or  of  a  soft 
tumour. 

The  misconception  that  may  arise  from  a  restricted  study 
of  statistics  is  well  shown  by  the  fact  that  out  of  1,348  examples 
of  cancer  of  the  stomach  which  we  have  collected  and  analysed 
according  to  the  method  employed  by  Brinton,  863,  or  64  per 
cent.,  were  described  as  'soft,' '  fungoid,'  '  medullary,'  or  '  ence- 
phaloid '  growths  ;  447,  or  33  percent.,  as  'hard'  or  'scirrhus,' 
and  thirty-eight,  or  2-9  per  cent.,  as  '  colloid.'  These  conclusions, 
while  they  agree  closely  with  those  arrived  at  by  Welch,  are 
diametrically  opposed  to  the  teaching  of  Brinton. 

The  only  certain  method  of  determining  the  character  of  a 
growth  is  by  submitting  it  to  a  microscopical  examination  ;  but, 
unfortunately,  comparatively  few  of  the  recorded  cases  have 
been  studied  in  this  way.  Perry  and  Shaw  examined  forty-four 
museum  specimens  of  gastric  cancer,  and  found  that  thirty-two 
belonged  to  the  spheroidal-cell  and  twelve  to  the  cylindrical- 
cell  type  ;  while  out  of  115  cases  of  our  own,  seventy-three,  or 
635  per  cent.,  were  described  as  spheroidal-celled,  thirty-three,  or 
28-6  percent.,  as  cylindrical-celled,  and  nine,  or  7*8  per  cent.,  as 
exhibiting  signs  of  colloid  degeneration.  It  may  also  be  observed 
that  out  of  forty-one  cases  of  spheroidal-celled  carcinoma,  it  was 
especially  noted  that  twenty-two  were  of  the  soft  or  medullary 
varietsT,  and  nineteen  of   the  hard  or  scirrhous  type.     These 


MOEBID  ANATOMY  AND  HISTOLOGY 


21 


figures  appear  to  indicate  that  spheroidal-celled  carcinomata  are 
more  than  twice  as  common  as  the  cylindrical-celled  variety, 
and  that  colloid  degeneration  can  frequently  be  detected  by  the 
microscope  when  invisible  to  the  naked  eye. 

Situation. — The  symptoms  of  the  disease  depend  so  much 
upon  its  situation  that  the  question  of  location  is  one  of  con- 
siderable importance.  All  writers  are  agreed  that  the  pylorus 
is  more  often  implicated  than  any  other  region  of  the  stomach  ; 
although  whether  the  growth  commences  at  the  valve  and 
spreads  inwards,  or  develops  near  the  orifice  and  becomes 
sharply  limited  by  the  valve,  is  a  point  which  is  not  only  im- 
possible to  decide,  but  one  that  is  not  endowed  with  any  special 
value.  According  to  Brinton,  60  per  cent,  of  all  gastric  cancers 
are  situated  at  the  pylorus ;  Lebert's  estimate  wTas  596  per 
cent.,  Katzenellenbogen's  58-3  per  cent.,  Luton's  57  per  cent., 
Welch's  608  per  cent.,  and  Hahn's  36  per  cent.  In  our  own 
series  of  265  cases  the  pylorus  was  primarily  affected  in  173,  or 
65-3  per  cent. ;  while  in  1,850  cases  which  we  have  collected 
from  different  sources,  the  disease  was  located  in  this  region  in 
58  per  cent. 


Table  1. — An  Analysis  of  1,850  Cases  of  Carcinoma  of  the  Stomach,  showing 
the  Frequency  of  the  Disease  in  different  Eegions  of  the  Organ 


Site      . 

Pylorus 

Lesser 
curva- 
ture 

214 

Cardia 

Pos- 
terior 
wall 

Great 
curva- 
ture 

An- 
terior 
wall 

Fundus 

Whole 

or 

greater 

part 

Multiple 
growths 

54 

No.  of  cases  . 

'  1072 

183 

94 

52 

41 

29 

111 

Per  cent. 

58 

11-5 

9-8 

5 

2-8 

2-2 

1-5 

6 

2-9 

Next  to  the  pylorus  in  order  of  frequency  comes  the  lesser 
curvature,  with  the  contiguous  parts  of  the  two  surfaces,  which 
were  the  seat  of  the  disease  in  11*5  per  cent.  The  cardiac 
orifice,  with  the  tissues  immediately  around  it,  was  affected  in 
9*8  per  cent.,  while  the  fundus,  which  often  escapes  when  the 
greater  portion  of  the  stomach  is  involved,  was  primarily 
attacked  in  only  1*5  per  cent.  The  growth  was  limited  to  the 
posterior  wall  in  about  5  per  cent.,  to  the  anterior  surface  in 
2-2  per  cent ,  and  to  the  great  curvature  in  2-8  per  cent.,  while 
the  whole  or  greater  part  of  the  viscus  was  implicated  in  6  per 
cent.     The  stomach  presented  two  or  more  separate  tumours 


22  CANCEE  OF  THE   STOMACH 

in  2-9  per  cent.  These  facts  indicate  that  in  794  per  cent.,  or 
in  about  four-fifths  of  all  cases,  carcinoma  commences  in  the 
comparatively  small  strip  of  tissue  which  extends  from  one 
orifice  to  the  other  along  the  upper  margin  of  the  stomach,  and 
that  its  percentage  incidence  rapidly  diminishes  the  further  we 
proceed  from  the  pyloric  valve. 

Relation  of  the  Type  of  Disease  to  its  Location. — It  is 
usually  taught  that  the  orifices  of  the  stomach  are  most  fre- 
quently attacked  by  scirrhus,  while  the  body  of  the  organ  is 
the  seat  of  the  medullary  and  adenomatous  forms  of  carcinoma. 
This  statement,  however,  is  hardly  borne  out  by  the  results  of  a 
microscopical  investigation.  In  forty-two  cases  of  pyloric  cancer 
we  find  that  twenty-nine  were  described  as  'spheroidal-cell,' 
and  thirteen  as  '  cylindrical-cell.'  Of  the  former,  twenty-one 
presented  an  excess  of  fibrous  stroma,  and  may  therefore  be 
regarded  as  '  scirrhus,'  while  in  eight  there  was  a  preponder- 
ance of  the  cellular  elements,  which  is  characteristic  of  the 
medullary  variety.  It  is  worthy  of  notice  that  the  scirrhus 
was  usually  limited  in  extent,  and  by  its  contraction  had  pro- 
duced stenosis  of  the  pyloric  orifice,  while  the  more  diffuse  in- 
filtration of  medullary  cancer  often  gave  rise  to  a  rigid  patency 
of  the  valve.  Of  the  thirteen  examples  of  adeno-carcinoma,  six 
took  the  form  of  a  diffuse  infiltration,  five  of  soft  fungating 
growths,  and  two  of  a  narrow  ring  which  encircled  the  stomach 
about  three  inches  from  the  pylorus.  Owing  to  the  non-contrac- 
tile nature  of  the  disease,  marked  stenosis  of  the  orifice  was 
seldom  observed.  Nineteen  cases  of  cancer  of  the  cardiac 
orifice  were  examined,  of  which  sixteen  possessed  a  spheroidal- 
cell  and  three  a  cylindrical-cell  structure.  Of  the  former, 
fourteen  exhibited  comparatively  little  stroma,  and  usually 
formed  soft  tumours  or  deep  ulcerations,  while  in  the  other 
two  the  orifice  was  greatly  narrowed  by  the  contraction  of  the 
fibrous  elements  of  the  growth  (scirrhus) .  The  three  examples 
of  adenocarcinoma  occurred  as  soft  ulcerating  tumours  near  the 
lesser  curvature,  on  the  inner  side  of  the  oesophageal  opening. 
Out  of  fourteen  cases  where  the  posterior  wall  or  lesser  curva- 
ture was  primarily  affected,  eight  were  spheroidal-celled  and  six 
cylindrical-celled,  while  an  examination  of  eleven  cases  of  infil- 
tration of  the  entire  stomach  showed  that  nine  consisted 
of  spheroidal-celled  cancer  and  only  two  of  the  cylindrical-celled 
type. 


MOEBID  ANATOMY  AND  HISTOLOGY  23 

Table  2 


Type 

Cases 

Pylorus 

Curvatures 

and 

surfaces 

Can.lia 

General 
infiltration 

Spheroidal-cell . 

62 

29 

8 

16 

9 

Cylinder-cell 

24 

13 

6 

3 

2 

From  these  facts  several  general  conclusions  may  be  drawn. 

(1)  Neither  of  the  two  fundamental  forms  of  carcinoma  exhibits 
a  special  predilection  for  any  particular  region  of  the  stomach. 

(2)  Circumscribed  tumours  of  the  orifices  which  produce 
stenosis  are  usually  hard  spheroidal-celled  (scirrhus) .  (3)  Diffuse 
infiltrations  of  the  pyloric  region  or  of  the  greater  portion  of 
the  viscus,  if  accompanied  by  a  contraction  of  the  tissues,  are 
usually  of  the  spheroidal-cell  type,  while  those  which  give  rise 
to  rigidity,  without  marked  diminution  in  the  capacity  of  the 
organ,  are  frequently  of  the  cylindrical-cell  variety.  (4)  A  ring 
of  new  growth,  which  separates  the  stomach  into  two  cavities 
of  unequal  size,  is  usually  composed  of  adenocarcinoma,  but 
globular  or  flattened  tumours  and  malignant  ulcerations  are 
most  often  spheroidal-celled  cancers.  (5)  Adenocarcinoma  is 
comparatively  rare  as  a  primary  growth  near  the  oesophageal 
opening. 

Multiple  Carcinomata.-  -According  to  the  statistics  quoted 
in  the  first  table,  in  about  3  per  cent,  of  all  cases  the 
stomach  exhibits  two  or  more  separate  growths.  The  question 
therefore  arises  whether  they  should  be  regarded  as  multiple 
primary  cancers,  or  as  examples  of  primary  and  secondary 
growths  occurring  in  the  same  organ.  In  about  three-fifths  of 
the  cases  which  we  have  collected  the  tumours  were  situated 
at  corresponding  spots  on  the  opposed  surfaces.  Thus,  in  one 
instance  a  malignant  ulcer  was  present  on  the  posterior  wall  a 
few  inches  from  the  pylorus,  and  exactly  opposite  to  it  there 
was  a  f ungating  mass  one  inch  and  a  half  in  diameter,  both 
tumours  consisting  of  spheroidal-celled  carcinoma.  A  similar 
instance  occurred  at  the  cardiac  end  of  the  viscus ;  and  Lunn 
has  described  a  case  in  which  two  small  medullary  tumours 
situated  opposite  one  another  in  the  pyloric  region  had  caused 
obstruction  to  the  outlet  by  their  mutual  contact.  It  can 
usually  be  observed  that  one  of  the  tumours  is  of  more  recent 


24  CANCER  OF  THE   STOMACH 

formation  than  the  other ;  and  since  in  all  our  cases  they  were 
identical  in  structure,  there  is  little  difficulty  in  attributing  the 
formation  of  the  second  growth  to  infection  by  contact.  In 
a  second  form  of  multiple  cancers,  of  which  Devic  and  others 
have  recorded  examples,  two  or  more  are  found  upon  the  same 
surface  of  the  viscus,  but  separated  from  one  another  by  healthy 
mucous  membrane.  As  a  rule  they  all  exhibit  the  same  histo- 
logical features,  and  their  mode  of  development  can  either  be 
traced  to  erratic  lymphatic  infection,  or  be  explained  by  the 
theory  of  the  transplantation  of  particles  detached  from  the 
earlier  growth.  There  yet  remain,  however,  certain  cases 
which  hardly  admit  of  explanation  by  the  theory  of  auto-infec- 
tion. These  are  characterised  by  the  simultaneous  implication 
of  two  portions  of  the  stomach,  usually  the  orifices,  by  cancerous 
growths,  which  may  even  possess  a  different  structure.  Thus, 
in  one  of  our  cases  the  cardiac  orifice  was  found  to  be  almost 
entirely  occluded  by  a  soft  spheroidal-celled  growth,  while  the 
pyloric  region  was  infiltrated  with  a  cylindrical-celled  cancer, 
and  Ripley,  Maurizio,  and  Barth  have  each  described  primary 
cancer  of  the  cardiac  and  pyloric  apertures  in  the  same  subject. 
The  fact  that  two  or  more  organs  of  the  body  may  become 
affected  by  cancer  at  the  same  time  has  long  been  recognised. 
Clark  and  J  ackson  have  recorded  instances  of  contemporaneous 
disease  of  the  uterus  and  stomach ;  V.  Winiwarter  mentions  one 
in  which  scirrhus  of  the  breast  was  associated  with  a  cylindrical 
epithelioma  of  the  jejunum  ;  and  other  examples  are  to  be  found 
in  the  writings  of  Kaufrmann  and  Beck.  Our  own  series  con- 
tains two  cases  of  particular  interest.  In  the  first  a  spheroidal- 
celled  cancer  of  the  pylorus  coexisted  with  a  cylindrical-celled 
epithelioma  of  the  rectum,  and  in  the  second  there  were  ap- 
parently primary  growths  of  different  kinds  in  the  bladder, 
stomach,  and  sigmoid  flexure.  "While,  therefore,  it  must  be  con- 
ceded that  the  majority  of  cases  where  several  growths  exist  in 
the  stomach  may  be  explained  by  some  theory  of  auto-infection, 
there  remain  a  certain  number  which  can  only  be  regarded  as 
examples  of  multiple  primary  cancerous  tumours. 

Secondary  Carcinoma  of  the  Stomach. 

It  is  commonly  stated  that  secondary  cancer  of  the  stomach 
is  extremely  rare,  and  writers  formerly  accorded  considerable 


MOEBID  ANATOMY  AND  HISTOLOGY  25 

prominence  to  a  case  in  which  Cohnheim  discovered  a  nodule 
of  scirrhus  in  the  stomach  after  death  from  a  similar  affection  of 
the  breast.  Eecent  investigations,  however,  tend  to  show  that 
the  phenomenon  in  question  is  by  no  means  so  uncommon  as  is 
usually  believed.  Welch  was  able  to  collect  thirty-seven  exam- 
ples without  exhausting  the  available  literature,  Ely  fourteen, 
and  de  Castro  twenty-two ;  while  in  our  own  series  of  265 
necropsies  upon  cancer  of  the  stomach,  nineteen,  or  7  per  cent., 
were  secondary  to  disease  of  some  other  organ.  This  latter 
estimate  closely  agrees  with  the  conclusions  arrived  at  by 
Hale  White,  who  states  that  6  to  7  per  cent,  of  all  gastric 
carcinomata  are  of  secondary  origin. 

The  relative  frequency  with  which  one  or  other  viscus  of 
the  body  is  the  site  of  the  primary  complaint  is  found  to  vary 
with  the  method  employed  in  collecting  the  cases.  Thus 
Welch,  who  appears  to  have  consulted  a  great  mass  of  statistics 
relative  to  mammary  cancer,  found  that  in  nearly  one-half  the 
gastric  complaint  was  secondary  to  disease  of  the  breast ;  while 
in  the  statistics  of  Ely,  de  Castro,  Torok,  and  Wittelshofer  the 
mouth,  oesophagus,  uterus,  and  testicle  were  more  frequently 
affected. 

But  when  recourse  is  had  to  a  large  series  of  consecutive 
necropsies  performed  at  a  general  hospital,  thereby  avoiding 
the  errors  incidental  to  an  analysis  of  isolated  cases,  it  at  once 
becomes  evident  that  secondary  cancer  of  the  stomach  may 
arise  in  at  least  three  different  ways.  Thus,  we  find  that  out 
of  the  nineteen  instances  to  which  reference  has  been  made, 
no  less  than  fourteen,  or  73-6  per  cent.,  were  due  to  direct 
extension  of  the  disease  from,  some  neighbouring  organ  ;  that  in 
four,  or  21  per  cent.,  the  primary  complaint  was  situated  in  the 
upper  part  of  the  digestive  tract ;  while  in  only  one,  or  5  per 
cent.,  was  the  gastric  affection  of  the  nature  of  a  true  metastasis. 
These  results  are  of  sufficient  importance  to  merit  a  detailed 
description. 

(1)  Invasion  of  the  stomach  by  contiguity  may  ensue  from 
cancer  of  any  organ  in  its  immediate  vicinity.  Out  of  our 
fourteen  cases,  the  pancreas  was  the  seat  of  the  disease  in  six, 
the  transverse  colon  in  three,  the  lower  end  of  the  oesophagus 
in  two,  and  the  gall-bladder,  liver,  and  uterus  each  in  one.  Less 
frequently  the  peritoneum,  retro-peritoneal  glands,  the  adrenals 
or  ovaries  are  first  involved.     When  the  pylorus  is  invaded,  it 


26 


CANCEE  OP  THE   STOMACH 


often  presents  a  uniform  infiltration,  as  in  the  primary  com- 
plaint, with  considerable  thickening  of  the  serosa  ;  but  if  the 
posterior  wall  of  the  organ  or  the  fundus  is  implicated,  the 

growth  is  comparatively 
localised,  and  ulceration 
of  the  mucous  membrane 
is  by  no  means  infre- 
quent. Cancer  of  the 
lower  end  of  the  oeso- 
phagus seldom  spreads 
far  into  the  stomach, 
and  when  it  does  so,  it  is 
usually  along  the  line  of 
the  lesser  curvature.  It 
is  nearly  always  a 
squamous-celled  epithe- 
lioma, but  examples 
of  spheroidal-celled 

growths  are  more  fre- 
quent than  was  once 
believed.  In  peritoneal 
cancer  the  stomach  is 
invaded  from  without 
by  numerous  nodules, 
which  form  projections 
beneath  the  mucous 
membrane,  and  may 
even  produce  typical 
ulceration.  In  one  of 
our  cases  cancer  of  the 
uterus  spread  by  way  of 
the  great  omentum  into 
the  pylorus,  which  be- 
came greatly  contracted 
and  proved  the  imme- 
diate cause  of  death. 

(2)  The  undue   fre- 
quency with  which  the 
stomach  is  affected  in  cancer  of  the  tongue,  mouth,  nares,  and 
oesophagus  is  probably  due,  as  Kiebs  suggested,  to  the  detachment 
of  particles  of  growth,  which  are  swallowed,  and  subsequently 


Fig.  19. —  Squamous  epithelioma  of  oesophagus 
with  a  secondary  growth  in  the  stomach. 
(Museum  of  the  Royal  College  of  Surgeons.) 


MOEBID  ANATOMY  AND  HISTOLOGY  27 

become  engrafted  upon  the  gastric  mucous  membrane.  In 
one  case  of  this  kind  which  came  under  our  notice  an  ulcerated 
stricture  of  the  oesophagus  was  found  opposite  the  cricoid  carti- 
lage, and  another  and  apparently  more  recent  growth  three  inches 
lower  down  ;  while  at  the  inner  side  of  the  cardiac  orifice,  upon 
the  posterior  wall  of  the  stomach,  was  a  flattened  ulcerated  tumour 
which,  like  the  oesophageal  growths,  was  composed  of  flat-celled 
epithelioma.  In  another  instance,  where  the  primary  disease 
occurred  about  three  inches  above  the  cardiac  orifice,  a  large 
fun  gating  tumour  occupied  the  middle  of  the  lesser  curvature. 
Both  growths  consisted  of  spheroidal-celled  carcinoma.  As  a 
rule  the  gastric  tumour  is  solitary,  and  grows  in  the  cardiac  region 
of  the  viscus,  near  its  upper  border.  Ulceration  is  infrequent. 
(3)  Secondary  deposits  in  the  stomach  from  a  growth  in  an 
organ  remotely  situated  probably  arise  from  infection  of  the 
blood-stream,  and  are  usually  associated  with  metastases  in  the 
liver  or  lungs.  Out  of  thirty-one  cases  of  this  description 
which  we  collected,  the  breast  was  primarily  affected  in  twenty, 
the  right  testicle  in  two,  the  uterus  in  three,  the  bowel  in  two, 
the  skin  in  two,  and  the  kidney  and  adrenals  each  in  one.  The 
tumour  in  the  stomach  was  usually  solitary,  of  variable  size, 
situated  in  the  submucous  tissue,  and  rarely  accompanied  by 
ulceration. 

Histology 

It  is  difficult  to  trace  the  evolution  of  carcinoma  in  the 
stomach,  owing  to  the  extensive  destruction  of  the  tissues 
which  occurs  at  an  early  period  of  the  disease,  and  the  changes 
that  take  place  in  the  mucous  membrane  immediately  after 
death.  Most  of  our  knowledge  of  this  subject  has  been  derived 
from  the  observations  of  Hauser  upon  the  development  of 
cancer  in  the  base  of  a  simple  ulcer. 

Although  the  different  forms  of  growth  vary  considerably, 
both  in  their  macroscopic  appearances  and  histological  structure, 
they  nevertheless  possess  certain  features  that  are  common  to 
all,  and  which  serve  to  distinguish  them  from  other  tumours  of 
the  organ,  both  malignant  and  benign. 

The  earliest  signs  of  a  departure  from  the  normal  consist 
of  an  active  proliferation  of  the  epithelium  of  a  small  group  of 
glands,  which  leads  to  distension  of  the  tubules  with  cells  of 
various  shapes  and  sizes,  obliteration  of  their  lumina,  and  a 


23  CANCEB  OE  THE   STOMACH 

marked  alteration  of  their  outlines.  At  the  same  time  the 
capillaries  which  ramify  in  the  deeper  portions  of  the  mucous 
membrane  become  engorged  with  blood,  and  exudation  of 
leucocytes  takes  place,  accompanied  by  proliferation  of  the 
corpuscles  of  the  connective  tissue  and  enlargement  of  the 
solitary  lymphatic  follicles.  Many  of  the  newly  formed  cells 
exhibit  particles  of  brownish  black  pigment,  and  the  oxyntic 
cells  of  the  neighbouring  glands  are  often  affected  in  a  similar 
manner.  The  epithelial  overgrowth  soon  gives  rise  to  elonga- 
tion, twisting,  and  distortion  of  the  tubules,  which  causes  them 
to  appear  branched  or  racemose  ;  while  the  ducts  become  choked 
with  debris  and  their  columnar  cells  rilled  with  mucus.  Up 
to  this  period  the  morbid  process  closely  resembles  an 
adenoma ;  but  it  now  displays  its  malignant  character  by  the 
rupture  of  the  basement  membranes  of  the  affected  glands  and 
escape  of  the  epithelium,  which  continues  to  penetrate  the 
surrounding  connective  tissue  in  the  form  of  branching  columns 
similar  in  appearance  to  the  peptic  glands,  but  devoid  of  a  mem- 
brana  propria.  This  extension  chiefly  takes  place  through  the 
lymphatic  spaces ;  but  many  of  the  cells  become  detached,  and 
wander  in  an  amoeboid  manner  through  the  tissues,  where  they 
produce  new  foci  of  disease  at  a  considerable  distance  from  its 
primary  seat.  Within  a  short  time  the  muscularis  mucosas 
becomes  involved,  and  its  fibres  are  separated  and  compressed 
by  an  invasion  of  the  intermuscular  lymphatic  channels. 
After  reaching  the  submucosa  the  columns  of  cells  continue  to 
invade  the  lymph-spaces  in  all  directions,  while  the  connective- 
tissue  elements  actively  proliferate,  and,  being  reinforced  by  an 
inflammatory  exudation  of  small  round  cells,  become  converted 
into  a  fibrous  reticulum  or  stroma,  the  amount  of  which  is 
usually  in  inverse  proportion  to  the  number  of  cells.  When 
the  latter  are  in  excess,  the  meshes  or  alveoli  of  the  stroma  are 
of  considerable  size  and  closely  set ;  but  when  the  fibrous  tissue 
predominates  the  spaces  are  usually  small  and  scanty,  and  may 
only  appear  as  fissures  containing  irregular  groups  or  rows 
of  cells.  The  epithelium  itself  varies  considerably  in  character, 
in  some  cases  consisting  of  quadrilateral  cells  arranged  in 
layers,  the  deepest  of  which  may  be  distinctly  columnar,  while 
in  others  the  alveoli  are  stuffed  with  cells,  whose  mutual 
pressure  causes  them  to  appear  round,  ovoid,  or  polyhedral. 
Each  cell   contains  one  or  more  nuclei,   which  often  exhibit 


MOEBID  ANATOMY  AND  HISTOLOGY  29 

atypical  mitoses,  and  occasionally  the  cell-enclosures  or  '  para- 
sites '  described  by  Soudakewitsch  and  Ruffer  may  be  detected 
in  them.  Multiplication  takes  place  both  by  budding  and  by 
karyokinesis.  The  smaller  vessels  of  the  submucosa  are  also 
affected  by  a  round-cell  infiltration  of  their  outer  coats  and  a 
hyperplasia  of  their  intima,  while,  according  to  Cornil  and 
Eanvier,  they  often  present  minute  aneurysmal  dilatations. 
These  changes  are  apt  to  result  in  the  formation  of  thrombi  in 
the  veins,  with  subsequent  invasion  of  the  clot  by  the  epithelial 
cells  which  have  penetrated  the  vascular  wall.  Although  the 
loose  structure  of  the  submucous  coat  of  the  stomach  offers 
every  facility  to  the  spread  of  the  disease  by  continuity,  the 
marked  preference  exhibited  to  lymphatic  invasion  leads  to 
an  early  dissemination  of  the  cells  through  the  surrounding 
tissues,  and  especially  in  the  direction  of  the  serosa.  At  first 
thin  rows  of  cells  are  observed  in  the  intermuscular  septa, 
where  they  provoke  an  inflammatory  thickening  of  the  con- 
nective tissue  and  induce  compensatory  hypertrophy  of  the 
muscular  fibres.  Thence  they  extend  towards  the  peritoneum, 
and  either  form  a  thick  layer  beneath  the  serous  membrane 
or  numerous  isolated  groups  in  the  lymphatic  vessels.  Sub- 
sequently cells  appear  between  the  individual  fibres  of  the 
muscular  coat,  while  the  ever-increasing  infiltration  of  the 
septa  compresses  the  contractile  tissue  and  eventually  leads 
to  its  fatty  degeneration  and  atrophy. 

The  abnormal  stimulation  of  the  tissues  excited  by  the 
epithelial  invasion  results  in  the  formation  of  new  blood-vessels 
by  a  process  of  budding  from  the  pre-existing  vascular  channels. 
This  increased  vascularisation  exerts  an  important  influence 
upon  the  subsequent  course  of  the  disease,  for  although  at  first 
it  is  conducive  to  rapid  growth,  the  newly  formed  vessels  are 
very  apt  to  rupture  and  to  give  rise  to  hemorrhagic  infiltration 
and  sloughing  of  the  tumour.  In  every  instance,  also,  the 
gradual  obliteration  of  the  original  vessels  due  to  their  com- 
pression or  thrombosis  diminishes  the  nutrition  of  the  growth, 
and  leads  to  degeneration  of  its  substance.  So  remarkable, 
indeed,  is  this  tendency  to  retrogressive  metamorphosis  that  it 
may  be  said  that  carcinomatous  tissue  is  characterised  from 
the  outset  by  degeneration.  In  most  cases  fatty  changes 
develop  first  in  the  cells  situated  in  the  centres  of  the  alveoli ;  but 
in  others  the  stroma  is  converted  into  colloid  material,  and  the 


30  CANCEE  OF  THE    STOMACH 

cells  subsequently  undergo  myxomatous  degeneration.  These 
latter  changes  are  most  frequently  encountered  in  the  cylin- 
drical-celled variety  of  the  disease.  At  first  the  mucous 
membrane  around  the  growth  is  affected  by  a  chronic  form  of 
inflammation,  which  produces  considerable  thickening  of  the 
interglandular  connective  tissue  and  is  accompanied  by  catarrhal 
changes  in  the  peptic  cells.  The  contraction  of  this  newly 
formed  tissue  compresses  and  distorts  the  glands,  and  often  gives 
rise  to  small  retention  cysts.  In  the  case  of  a  slow-growing 
hard  carcinoma,  this  gastritis  may  proceed  to  atrophy  of  the 
secretory  structures  before   they  are  actually  invaded  by  the 


Fig.  20. — Scirrhous  carcinoma  of  the  stomach  (  x  100). 

disease  ;  but  in  the  softer  forms  the  atypical  epithelium  soon 
penetrates  both  the  tubules  and  the  tissue  that  separates  them, 
and  completely  destroys  the  mucous  membrane  at  a  compara- 
tively early  period. 

Scirrhous  carcinoma  is  characterised  by  the  presence  of  an 
excess  of  stroma  and  a  marked  deficiency  of  the  cellular 
elements.  All  the  coats  of  the  stomach  are  much  thickened, 
and  the  submucosa  consists  almost  entirely  of  greyish-white 
coarse,  fibrillated  cicatricial  tissue,  which  here  and  there  may 
exhibit  a  small  hollow  or  fissure  containing  a  few  epithelial 
cells.  The  muscular  layer  is  much  hypertrophied,  and  its 
fibres  are  enclosed  in  a  meshwork  of  fibrous  tissue  produced 


MOEBID  ANATOMY  AND  HISTOLOGY  31 

by  ",thickening  of   the  intermuscular   septa.      There  is  also  a 
notable  induration  of  the  subserous  connective  tissue,   while 


Fig.  21. — Scirrhous  carcinoma  of  the  stomach  (  x  430). 


Fig.  22.— Cylinder-celled  carcinoma  of  the  stomach  (  x  100). 

the   mucous   membrane    shows    signs    of   chronic   interstitial 
gastritis, 


32  CANCEE  OF  THE   STOMACH 

Medullar y  carcinoma  differs  from  the  preceding  in  the 
excessive  number  of  cells  it  contains  and  the  relative  defici- 
ency of  stroma.  The  alveoli  are  large  and  numerous,  and  filled 
with  cells  of  a  round  or  oval  shape.  Infection  of  the  deeper 
tissues  occurs  through  the  lymphatic  vessels,  and  rows  of  cells 
may  be  observed  in  the  intermuscular  septa  and  immediately 
beneath  the  serous  membrane  even  before  the  growth  in  the 
submucosa  has  made  any  substantial  progress.  The  mucous 
membrane  is  also  invaded  and  destroyed  at  a  comparatively 
early  period. 

Cylindrical-celled  carcinoma. — In  this  variety  the  alveoli  are 
large  and  of  various  sizes  and  shapes,  and  are  supported  by  a 
delicate  stroma  rich  in  blood-vessels.  By  mutual  compression 
the  cells  assume  different  forms,  and  it  may  only  be  the  deepest 
layer  that  presents  the  typical  columnar  shape,  while  it  is  often 
impossible  to  distinguish  some  parts  of  the  section  from  the 
spheroidal-celled  variety.  Colloid  degeneration  is  more  frequent 
in  this  form  than  in  the  others  (fig.  22). 

Colloid  carcinoma  presents  a  fine  meshwork  of  connective 
tissue,  which  encloses  a  large  quantity  of  clear  rnuco-colloid 
material.  No  cellular  elements  may  exist,  or  here  and  there  a 
few  cells  or  fragments  may  be  detected.  At  the  margin  of  the 
tumour  the  usual  appearances  of  carcinoma  are  to  be  found ;  and 
the  process  of  degeneration  may  be  traced  in  the  development 
of  clear  globules  in  the  substance  of  the  cells,  which  gradually 
coalesce  and  destroy  the  regularity  of  their  outline. 


33 


CHAPTEE   II 

THE  SEQUEL M   OF  CARCINOMA 

1.  Adhesions 

The  formation  of  adhesions  around  the  seat  of  the  disease 
is  of  considerable  importance  both  as  regards  diagnosis 
and  also  surgical  treatment.  The  adhesions  themselves  vary 
considerably  in  different  cases,  in  some  being  of  recent  forma- 
tion and  so  soft  that  they  are  easily  broken  down  by  the 
finger,  while  in  others  the  abdominal  viscera  are  so  firmly 
matted  together  that  it  is  impossible  to  separate  one  organ 
from  another.  In  one  form  or  another  they  exist  in  the  vast 
majority  of  the  cases  in  which  the  disease  has  run  its  usual 
course,  but  the  frequency  with  which  the  more  important 
variety  is  met  with  has  been  variously  estimated  by  different 
writers.  Debelut  found  well-marked  adhesions  in  one-half  of 
the  cases  he  collected,  and  Osier  in  about  56  per  cent,  of 
those  which  came  under  his  observation.  Gussenbauer  and 
V.  Winiwarter  noted  their  existence  in  370  out  of  542  cases  of 
pyloric  cancer  (68  per  cent.),  while,  in  300  cases  in  which 
laparotomy  was  undertaken  for  the  relief  of  the  disease,  Guinard 
states  that  the  pylorus  was  only  perfectly  movable  in  fourteen,  or 
about  5  per  cent.  In  our  own  series  of  265  fatal  cases,  adhesions 
were  sufficiently  numerous  to  attract  the  attention  of  the  patho- 
logist in  213  instancss,  or  in  80  per  cent.  It  may  therefore  be 
accepted  that  in  about  four-fifths  of  all  cases  the  affected  region 
of  the  stomach  is  adherent  to  some  neighbouring  organ  at  the 
time  of  death. 

The  situation  of  the  growth  exerts  a  certain  amount  of 
influence  upon  the  formation  of  adhesions.  This  is  shown  in 
the  following  table. 


34 


CANCEE  OF  THE   STOMACH 
Table  3 


Situation  of  growth 

Xo.  of  cases         Adhesions  present          Percentage 

Pylorus  ..... 
Cardia 

Lesser  curvature     . 
Posterior  wall 
Greater  curvature  . 
General  infiltration 

173 
24 
29 
13 
6 
20 

139                        80-3 
18                         75-0 
26                        89-6 

12  92-3 
5                        83-3 

13  6-5-0 

265                        213                          — 

In  order  that  plastic  perigastritis  should  be  set  up  it  is  neces- 
sary that  either  the  neoplasm  itself  or  its  toxic  products  should 
gain  entrance  to  the  subserous  lymphatics,  and  it  is  consequently 
found  that  adhesions  are  most  frequent  and  extensive  in  those 
cases  in  which  the  disease  has  infiltrated  the  whole  thickness 
of  the  gastric  wall  or  has  undergone  ulceration.  Both  con- 
ditions are  best  exemplified  in  the  soft  spheroidal-celled  cancers, 
which  rapidly  penetrate  the  muscular  coat  and  produce  deep 
ulcers.  The  cylindrical-celled  variety,  although  at  first  chiefly 
confined  to  the  submucous  tissue,  is  apt  to  slough,  and  is 
therefore  rarely  unaccompanied  by  adhesions  after  the  lapse  of 
a  few  months.  A  localised  scirrhus  of  the  pylorus,  on  the  other 
hand,  often  grows  very  slowly,  and  not  infrequently  gives  rise 
to  fatal  vomiting  without  having  excited  sufficient  inflammation 
of  the  peritoneum  to  fix  the  part  to  a  neighbouring  viscus. 

Disease  of  the  pylorus  and  the  lesser  curvature  usually  gives 
rise  to  adhesions  with  the  under  surface  of  the  right  lobe  of  the 
liver,  while  a  growth  of  the  cardia  either  involves  the  same 
organ  or  the  pancreas.  When  the  posterior  wall  is  the  seat  of 
ulceration,  the  pancreas  is- almost  always  affected,  and  in  many 
instances  the  stomach  also  becomes  united  to  the  vertebral 
column.  A  neoplasm  of  the  great  curvature  is  particularly  apt 
to  invade  the  transverse  colon,  and  in  those  rare  cases  in  which 
the  fundus  is  primarily  affected  the  spleen  often  becomes 
attached  to  the  base  of  the  disease.  It  is  comparatively  rare 
for  only  one  organ  to  be  involved  in  adhesions,  since  the  inflam- 
mation of  the  peritoneum  soon  spreads  to  the  other  abdominal 
viscera.  In  our  series  of  cases  two  or  more  organs  were  firing 
united  in  about  70  per  cent,  of  those  in  which  adhesions  occurred  ; 
while  in  about  10  per  cent,   all   the  viscera  were   so   matted 


THE   SEQUELAE   OF  CAECINOMA 


35 


together   that  it  was  impossible  to   separate    one  organ  from 
another. 

Table    4. 


Organs  adherent 

Liver  only    . 
Colon  only  . 
Pancreas  only 
Uterus  only 
Abdominal  wall    . 
Two  or  more  organs 

Cancer  of  pylorus 

Cancer  of  cardia 

Cancer  of  lesser 
curvature  or 
posterior  wall 

23% 
5% 
6% 
1-5% 
1-5% 

63% 

9% 
16% 

75% 

11% 

19% 

2-6% 
67-4% 

100% 

100% 

100% 

Effects  of  Adhesions. — The  development  of  perigastritis  is 
an  important  factor  in  the  spread  of  carcinoma,  since  the  morbid 
growth  rapidly  infiltrates  the  newly  formed  connective  tissue, 
and  thus  extends  by  direct  continuity  into  the  wall  of  the 
attached  structure.  In  this  manner  fresh  foci  are  constantly 
forming  at  the  base  of  the  disease  and  infecting  new 
systems  of  blood-vessels  and  lymphatics.  If  the  intestine 
happens  to  be  involved,  the  neoplasm  either  compresses  its 
lumen  and  occasions  symptoms  of  obstruction,  or  it  gradually 
destroys  its  coats,  with  the  ultimate  production  of  a  fistula. 
Finally,  implication  of  the  lymphatic  vessels  of  the  peritoneum 
may  lead  to  general  carcinoma  of  that  serous  membrane  and  of 
the  pleurae,  or,  should  the  receptaculum  chyli  be  attacked,  the 
materies  morbi  may  gain  an  entrance  to  the  general  circulation. 

Fixation  of  the  stomach  to  an  organ  in  its  vicinity  tends 
to  trammel  its  movements  and  so  to  increase  its  tendency  to 
dilatation.  This  result  is  especially  noticeable  in  cases  of 
adhesion  between  the  pylorus  and  the  liver,  since  the  weight 
of  the  viscus  dragging  upon  its  fixed  point  produces  a  kink, 
which  greatly  hinders  the  propulsion  of  the  chyme  into  the  intes- 
tine ;  indeed,  this  form  of  obstruction  is  responsible  in  great 
measure  for  the  gastric  dilatation  that  usually  accompanies 
non-stenosing  carcinoma  of  the  pylorus  or  first  part  of  the 
duodenum.  Similarly,  the  contraction  of  adhesions  between 
the  cardiac  end  of  the  stomach  and  the  liver  or  pancreas  often 
twists  and  obstructs  the  lower  end  of  the  oesophagus ;  while 
universal  adhesion  of  the  abdominal  viscera  may  compress  the 
stomach  and  greatly  reduce  its  cubic  capacity.     In  not  a  few 


D    2 


36  CANCEE  OF  THE   STOMACH 

cases  the  formation  of  adhesions  is  also  responsible  for  certain 
difficulties  of  diagnosis.  Thus,  it  is  not  uncommon  for  the 
pylorus  to  be  drawn  up  beneath  the  liver  so  as  to  obscure  the 
existence  of  a  tumour,  and  for  compression  of  the  bile  duct  or 
portal  vein  to  occasion  early  jaundice  or  ascites,  and  in  this  way 
to  distract  attention  from  the  primary  complaint.  On  the  other 
hand,  peritoneal  adhesions  perform  the  useful  part  of  limiting 
the  diffusion  of  the  gastric  contents  in  cases  of  perforation, 
and  thereby  of  preventing  general  peritonitis. 

2.  Changes  in  the  Shape  of  the  Stomach 

Carcinoma  is  almost  always  accompanied  by  some  altera- 
tion in  the  shape  of  the  stomach.  In  most  cases  this  takes  the 
form  of  an  increase  of  size,  but  occasionally  the  viscus  becomes 
greatly  thickened  and  contracted,  or  presents  some  less  regular 
deformity. 

It  is  usually  stated  that  disease  of  the  pylorus  is  always 
accompanied  by  gastric  dilatation,  owing  to  the  retention  and 
decomposition  of  the  food  which  ensue  from  obstruction  of 
the  orifice.  This,  however,  is  hardly  accurate,  since  many 
cases  of  pyloric  cancer  are  associated  with  contraction  rather 
than  dilatation  of  the  stomach,  while  gastric  enlargement 
may  exist  without  any  stenosis  of  the  outlet.  Thus,  Lebert 
found  that  out  of  twenty  cases  in  which  the  pylorus  was 
obstructed  the  stomach  was  dilated  in  thirteen  and  contracted 
in  seven ;  and  out  of  nine  instances  where  the  orifices  were 
free  from  disease  the  organ  was  dilated  in  four  and  contracted 
in  five.  Our  own  series  includes  ninety-eight  cases  of  pyloric 
disease  in  which  special  mention  is  made  of  the  size  of  the 
stomach  after  death  ;  of  these  the  organ  was  described  as 
'  much  dilated  '  in  forty-one,  '  dilated  '  in  eleven,  '  normal '  in 
ten,  and  '  contracted  :  in  thirty-six. 

It  is  therefore  obvious  that  the  stomach  varies  considerably 
in  size  in  different  cases,  even  when  affected  by  the  same  lesion, 
and  that  the  factor  which  determines  its  ultimate  condition 
may  often  be  independent  of  the  original  disease. 

A.    DILATATION 

In  its  most  pronounced  form  a  dilated  stomach  appears 
to  occupy  the  greater  part  of  the  abdominal  cavity,  and  in  such 


THE   SEQUELS  OF  CAECINOMA  37 

cases  the  pylorus  is  almost  always  found  to  be  the  seat  of  a 
localised  scirrhous  growth  which  has  reduced  the  outlet  to  a 
narrow  channel.  The  disease  is  often,  but  not  invariably, 
adherent  to  the  under  surface  of  the  liver,  and  the  walls  of  the 
viscus  are  peculiarly  thin  and  transparent.  The  clinical  history 
indicates  that  for  the  first  five  or  six  months  the  gradual  con- 
traction of  the  pylorus  was  accompanied  by  a  compensatory 
hypertrophy  of  the  muscular  wall  of  the  stomach,  the  forcible 
contractions  of  which  were  plainly  visible  through  the 
abdominal  parietes.  As  soon,  however,  as  the  general  nutri- 
tion became  seriously  impaired  the  contractile  power  rapidly 
failed,  and  the  signs  of  atony  and  dilatation  made  their 
appearance. 

A  moderate  degree  of  gastrectasis  often  accompanies  those 
varieties  of  carcinoma  which  produce  a  rigid  patency  of  the 
pylorus.  In  such  it  may  usually  be  observed  that  the  dilata- 
tion is  confined  to  the  central  and  cardiac  portions  of  the 
organ,  and  that  in  addition  to  the  increase  of  cubic  capacity  the 
muscular  coat  is  considerably  hypertrophied.  This  latter  con- 
dition points  to  the  existence  during  life  of  some  obstruction  to 
the  passage  of  food  into  the  intestine,  and  since  no  obvious 
obstruction  is  apparent  after  death,  it  must  have  arisen  from 
destruction  of  the  muscular  tissue  of  the  pyloric  segment  by 
the  new  growth.  A  parallel  to  this  is  to  be  found  in  the  dilated 
and  hypertrophied  state  of  the  lower  oesophagus  which  ensues 
from  paralysis  of  the  cardiac  sphincter. 

In  addition  to  these  two  main  factors  in  the  production 
of  gastric  dilatation,  viz.  stenosis  and  paralysis  of  the  pylorus, 
there  are  probably  several  others  which  aid  the  process  in  an 
adventitious  manner.  In  the  first  place,  every  case  of  carcinoma 
is  accompanied  by  a  diffuse  chronic  gastritis.  As  a  rule  the 
inflammatory  mischief  merely  affects  the  mucous  membrane  ; 
but  if  the  pylorus  is  contracted  or  the  growth  has  undergone 
extensive  ulceration,  it  often  spreads  to  the  muscular  tunic  and 
impairs  the  contractile  power  of  the  tissue.  Secondly,  the 
incompetency  of  the  pyloric  valve  which  results  from  its  infiltra- 
tion by  a  soft  growth  must  permit  of  the  constant  regurgitation 
of  fluids  and  gas  from  the  duodenum,  which  not  only  distend 
the  stomach,  but  continually  stimulate  its  secretory  and  motorial 
apparatus,  and  thus  induce  fatigue.  Lastly,  adhesions  between 
the  stomach   and  neighbouring  viscera  not  only  trammel  the 


38  CANCEE  OF  THE   STOMACH 

gastric  movements,  but  are  apt  to  twist  the  pylorus  or  upper 
part  of  the  duodenum  and  thus  to  produce  a  severe  form  of 
mechanical  obstruction. 

B.    CONTRACTION 

The  most  noticeable  examples  of  contraction  of  the  stomach 
are  met  with  in  cases  of  diffuse  scirrhous  infiltration,  when  the 
viscus  is  converted  into  a  thick  tube,  from  four  to  six  inches 
in  length,  and  closely  resembles  a  piece  of  small  intestine. 
Owing  to  the  dense  infiltration  of  the  submucosa  the  lumen  of 
the  organ  is  so  much  reduced  that  it  may  only  admit  a  catheter 
of  medium  size,  while  its  cubic  capacity  may  not  exceed  one  fluid 
ounce.  A  considerable  degree  of  contraction  also  arises  from 
general  infiltration  by  medullary  or  adeno-carcinoma,  but  as  a 
rule  the  shape  of  the  organ  is  better  preserved  and  its  cavity 
is  less  diminished. 

Diminution  in  the  size  of  the  stomach  without  direct  im- 
plication of  its  walls  is  a  frequent  result  of  non-retention  of 
food.  Almost  every  case  of  stricture  of  the  cardiac  orifice  is 
associated  with  a  contracted  stomach  ;  and  if  the  ingestion  of 
food  has  been  suspended  for  some  time  the  organ  may  be 
retracted  beneath  the  ribs,  and  reduced  to  the  size  and  shape  of 
an  orange.  In  like  manner,  certain  cases  of  pyloric  stenosis  are 
found  to  be  accompanied  by  a  contracted  rather  than  a  dilated 
stomach,  owing  to  the  excessive  vomiting  which  had  existed 
during  the  last  few  weeks  of  life  having  maintained  the  organ 
in  a  state  of  depletion.  Lastly,  secondary  carcinoma  of  the 
peritoneum  often  produces  such  dense  adhesions  between  the 
various  abdominal  viscera  that  the  stomach  is  compressed 
a,nd  its  cavity  almost  obliterated. 

C.    IBKEGULAK    DEFORMITY 

A  growth  situated  between  the  orifices  may  produce  con- 
siderable alteration  in  the  shape  of  the  stomach.  The  most 
frequent  deformity  from  this  cause  is  the  partial  division  of 
the  organ  into  two  sacs  (hour-glass  contraction).  As  a  rule 
the  disease  is  of  the  cylinder-celled  variety,  and  forms  a  narrow 
ring  round  the  pyloric  segment  about  three  inches  from  the 
orifice.  As  a  result  of  the  partial  obstruction  which  is  thus 
produced,  the  cardiac  sac  becomes  considerably  dilated  and  its 
muscular  coat  hypertrophied,  while  the  pyloric  portion  is  either 


THE   SEQUELAE   OF  CAECINOMA 


39 


normal  in  appearance  or  is  more  or  less  invaded  by  the  growth. 
In  other  cases  a  scirrhus  of  the  cardia  spreads  round  the  organ 
at  the  junction  of  the  fundus  with  the  central  portion,  and 
thus  divides  it  into  a  large  thin-walled  pyloric  sac  and  a  small 
hypertrophied  pouch  situated  immediately  beneath  the  lower 
end  of  the  oesophagus.  Less  frequently  the  constriction  Occurs 
in  the  centre  of  the  stomach,  and  should  "the  amount  of  in- 
filtration be  excessive,  the  organ  may  present  the  appearance  of 
a  dumb-bell.    This  rare  condition  is  well  shown  in  fig.  13,  p.  15, 


Fig.  23. — Scirrhous  carcinoma  of  the  cardiac  orifice  with  hour-glass  stomach. 
(Museum  of  the  Royal  College  of  Surgeons.) 


where  the  channel  of  communication  between  the  cardiac  and 
pyloric  pouches  measured  one  inch  and  a  half  in  length,  and 
barely  admitted  a  small  lead  pencil. 

The  other  varieties  of  deformity  hardly  require  a  detailed 
description.  A  contracting  growth  of  the  lesser  curvature 
tends  to  approximate  the  two  orifices,  with  consequent  kinking 
of  the  duodenum ;  while  an  irregular  extension  of  the  disease 
may  either  divide  the  viscus  into  three  or  four  sacs,  bend  it 
upon  itself,  or,  by  contracting  adhesions  with  the  uterus,  drag 
it  into  a  vertical  position. 


40  CANCEE   OE  THE   STOMACH 

3.  Ulceration 

According  to  Lebert  ulceration  is  met  with  in  three-fifths 
of  all  cancers  of  the  stomach ;  and  with  this  statement  our  own 
observations  closely  coincide,  since  we  find  that  it  was  present 
in  64" 5  per  cent,  of  our  cases.     It  occurs  most  frequently  among 
the   soft   medullary  growths,  but  it  is    also    common   in  the 
fungating  forms  of  adenocarcinoma  and  in  localised  scirrhus, 
though  it  is  rare  in  colloid.     The  ulcer  itself  varies  considerably 
in  appearance  in  different  cases.     In  the  soft  exuberant  growths 
it  usually  takes  the  form  of  a  deep   crater-like  excavation,  the 
edges  of  which  are  thickened,  irregular,  and  overhanging,  the 
walls   shaggy,  and  the  base  studded  with  villous    or  fungoid 
processes.     "When  the  tissues  of  the  stomach  are  affected  with 
a  diffuse  form  of  infiltration,  the  inner  surface  often  presents 
several  discrete  ulcers,  which  are  somewhat  oval  in  shape,  with 
their  long  axes  parallel  to  the  great  curvature.     Occasionally 
they  are    quite  superficial,   and  resemble  simple  abrasions   of 
the  mucous  membrane  ;  but  as  a  rule  the  edges  are  slightly 
thickened  and  everted,  while  the  base,  which  is  situated  in  the 
submucous    or  muscular  coat,  is  hummocky  or  terraced,  and- 
covered  with  fine  papillae  or  with  loops  of  blood-vessels.     In 
colloid  carcinoma  the  ulcer  is  usually  superficial,  and  has    a 
characteristic  reticulated  appearance. 

Although  carcinoma  is  most  frequent  in  the  pyloric  region, 
the  tendency  to  ulceration  appears  to  be  greatest  when  the 
growth  occupies  the  walls  of  the  viscus  in  the  vicinity  of  the 
curvatures. 

Table    5 


Situation    .        .              Pylorus 

Walls  and  curva-             Cardi^ 
tares 

General  infikration 

Ulceration     .              W 

68%                   52% 

46% 

This  is  probably  due  rather  to  the  type  of  the  disease  than 
to  any  influence  of  locality,  since  growths  of  the  central  regions 
of  the  viscus  are  usualty  of  the  medullary  or  villous  type,  which 
are  particularly  prone  to  ulcerate. 

The  size  of  the  ulcer  varies  considerably ;  in  some  cases  it 
hardly  exceeds  the  dimensions  of  a  split  pea  or  a  hemp-seed, 
while  in  others  tracts  of  tissue  several  inches  square  may  be 


THE   SEQUELS  OF  CAECINOMA  41 

involved,  or  almost  the  whole  of  the  inner  surface  of  the  organ 
may  be  affected  (fig.  12,  p.  14).  The  depth  of  the  ulcer  varies 
in  different  cases.  In  the  scirrhous  and  colloid  forms  of  the 
disease  it  is  comparatively  superficial  and  rarely  extends  beyond 
the  submucous  coat,  while  in  the  softer  growths  more  or  less 
destruction  of  the  muscular  layer  is  met  with  in  nearly  40  per 
cent.,  while  exposure  of  the  peritoneum  occurs  in  about  one- 
quarter  (27  per  cent.)  of  the  cases. 

The  different  features  which  are  thus  presented  by  a 
cancerous  ulcer  depend  to  a  great  extent  upon  its  mode  of 
formation.  In  scirrhus  the  solution  of  continuity  often  owes 
its  origin  to  stretching  of  the  mucous  membrane  by  the  sub- 
jacent growth,  and  to  its  partial  deprivation  of  arterial  blood 
by  the  pressure  exerted  upon  its  nutrient  vessels.  The  gradual 
devitalisation  which  is  thus  induced  renders  the  tissue  unable 
to  withstand  the  solvent  action  of  the  gastric  juice,  which  con- 
sequently gives  rise  to  superficial  erosion.  In  other  cases  the 
mucous  membrane  is  itself  invaded  by  the.  disease,  and  under- 
goes a  gradual  necrosis  as  the  result  of  the  retrograde  changes 
that  occur  in  the  new  tissue. 

The  extensive  ulceration  which  so  often  attacks  the  softer 
varieties  of  tumour  is  caused  either  by  softening  and  disintegra- 
tion of  the  growth,  or  by  gangrene  arising  from  thrombosis  of 
a  nutrient  artery.  In  the  former  case  the  process  is  a  gradual 
one,  and  while  the  central  portion  of  the  tumour  is  destroyed, 
rapid  proliferation  takes  place  in  the  surrounding  parts.  In 
the  latter,  large  masses  are  apt  to  slough  off,  with  imminent 
danger  to  the  integrity  of  the  gastric  wall  and  to  the  large 
blood-vessels  that  supply  it. 

Simple  ulceration  of  an  acute  character  occasionally  occurs 
along  with  carcinoma.  As  a  rule  it  develops  in  the  immediate 
vicinity  of  the  disease,  and  owes  its  origin  to  an  extension  of  the 
arterial  thrombosis  to  which  reference  has  just. been  made.  In 
other  cases  the  ulcer  appears  at  some  distance  from  the  growth, 
either  near  the  cardiac  orifice  or  in  the  first  part  of  the  duodenum. 
In  such  it  is  usually  found  that  the  patient  had  suffered  from 
the  symptoms  of  septicaemia  for  several  weeks  before  death,  and 
occasionally  the  mitral  valve  shows  signs  of  recent  endocarditis. 
It  is  probable,  therefore,  that  the  disease  originated  in  septic 
embolism,  as  in  ordinary  cases  of  pyseinia.  In  one  of  our  cases 
of  gastric  cancer  which  succumbed  to   fatal   haemorrhage  the 


42  CANCEE  OF  THE   STOMACH 

coronary  artery  was  found  to  have  been  eroded  by  a  srnall 
simple  ulcer  on  the  lesser  curvature  ;  while  in  another  fatal 
peritonitis  ensued  from  the  perforation  of  an  acute  ulcer  of  the 
duodenum.  On  the  other  hand,  a  chronic  simple  ulcer,  if  it 
precedes  the  carcinoma,  is  apt  to  be  invaded  by  the  malig- 
nant disease  ;  while  the  so-called  '  simple  ulcer,'  which 
occasionally  develops  opposite  the  growth,  is  always  found  on 
microscopical  examination  to  possess  a  cancerous  structure. 

4.  Haemorrhage 

Extravasation  of  blood  into  the  stomach  is  a  frequent  result 
of  malignant  disease.  In  the  majority  of  the' cases  it  is  very 
slight,  and  merely  imparts  a  brownish  or  black  tinge  to  the  gastric 
contents  ;  but  occasionally  the  patient  vomits  a  considerable 
quantity  of  florid  blood,  while  in  rare  instances  the  haemorrhage 
is  so  profuse  as  to  destroy  life.  It  is  therefore  convenient  to 
distinguish  three  varieties,  namely,  the  slight,  the  moderate,  and 
the  excessive. 

(1)  Slight  hemorrhage  probably  occurs  in  every  case  at 
some  period  of  its  course,  and  in  many  it  may  be  said  to  be 
almost  continuous.  It  is  met  with  in  all  forms  of  the  disease, 
but  is  most  frequent  in  growths  of  the  pylorus  and  of  the 
lesser  curvature.  The  blood  does  not  appear  to  be  derived  from 
any  particular  part  of  the  growth,  but  oozes  from  its  general 
surface  and  from  the  congested  mucous  membrane  around  it. 
As  a  rule  the  bleeding  originates  spontaneously,  and  is  particu- 
larly apt  to  occur,  during  the  period  of  digestion,  when  the 
determination  of  blood  to  the  stomach  is  greatly  augmented. 
It  is  probable,  however,  that  direct  irritation  of  the  vascular 
growth  by  particles  of  food  is  not  infrequently  an  exciting 
cause,  as  it  is  exceptionally  common  when  the  patient  indulges 
in  a  mixed  diet,  and  is  very  prone  to  follow  exploration  of 
the  stomach  with  a  tube.  In  other  cases  it  ensues  from 
local  embarrassment  of  the  circulation  consequent  upon  the 
thrombosis  of  a  small  vessel ;  while  occasionally  it  is  due 
to  the  rupture  of  one  of  the  varicose  veins  which  ramify  around 
the  base  of  the  disease. 

(2)  Moderate  hcemorrhage  was  estimated  by  Brinton  to 
occur  in  7  per  cent,  and  by  Lebert  in  12-5  per  cent,  of  all 
gastric    cancers.     In    our   own    series    of    150    clinical   cases 


THE   SEQUELS  OE  CAECINOMA  43 

moderate  hsematemesis  was  recorded  in  sixteen  instances,  or  in 
108  per  cent.  It  may  therefore  be  concluded  that  an  attack 
of  bleeding  similar  in  character  to  that  which  ensues  from  a 
simple  ulcer  occurs  in  10  to  12  per  cent,  of  all  cases  of 
carcinoma  of  the  stomach.  The  liability  to  this  form  of 
haemorrhage  is  greatest  when  the  disease  affects  one  of  the 
orifices,  though  it  is  by  no  means  infrequent  in  growths  of 
the  body  of  the  viscus  ;  and  its  occurrence  is  an  almost  certain 
indication  that  ulceration  has  taken  place. 

The  vessels  usually  eroded  are  the  submucous  and  subserous 
branches    of   the  superior   pyloric    or   coronary    arteries ;    but 


Fig.  24. — Diagram  of  the  stomach  and  duodenum,  showing  their  arterial 
blood-supply.  1,  coronary  artery  ;  2,  splenic  ;  3,  hepatic  ;  4,  pyloric  ; 
5,  gastro-duodenal ;  6,  right  gastroepiploic  ;  7,  8,  superior  pancreatico- 
duodenal ;  9,  left  gastro-epiploic. 

occasionally  sudden  sloughing  of  a  portion  of  the  growth  will 
simultaneously  destroy  several  of  its  small  nutrient  vessels.  It 
is  important  to  note  that  severe  haemorrhage  is  rarely  observed 
in  disease  of  the  pylorus  which  has  given  rise  to  marked 
stenosis.  This  phenomenon  may  be  explained  partly  by  the  fact 
that  a  contracting  cancer  of  the  pylorus  is  usually  scirrhus,  and 
consequently  less  liable  to  undergo  extensive  ulceration  than  the 
other  varieties,  and  partly  by  the  comparative  anaemia  of  the 
gastric  walls  that  results  from  the  long-continued  stretching 
and  dilatation  of  the  organ. 


44  CANCEE  OF  THE   STOMACH 

(3)  Excessive  licemorrliage,  leading  to  a  rapidly  fatal  termi- 
nation, is  extremely  rare.     Brinton  found  only  four  examples 
among  the  374  cases  of  cancer  of  the  stomach  he  collected  (about 
1  per  cent.),  and  our  own  series  of  autopsies  upon  the  disease  only 
contains   two  cases    (0-75  per  cent.)  in  which  death  resulted 
immediately  from  loss  of  blood.     The  accident  usually  arises 
from    the    sloughing    of    a    soft   growth    situated    upon    the 
posterior  wall  or  lesser  curvature.     In  fifteen  cases  where  exact 
details  are  given  we  find  that   the    coronary    artery   was  the 
source  of  the  haemorrhage  in  eight,  the  superior  pyloric  artery 
in  four,  the  splenic  artery  in  two,  and  the  right  gastro-epiploic 
artery  in  one.     In  rare  instances  the  morbid  growth  may  destroy 
a  large  vessel  in  some  neighbouring  organ,  such  as  the  liver, 
pancreas,  or  spleen,  or  it  may  erode  the  aorta,  vena  cava,  or  the 
portal  vein  (Cassimir-Broussais).    Considering  the  widespread 
destruction  wrought  by  a  cancerous  growth,  it  seems  at  first  sight 
somewhat  strange  that  severe  haemorrhage  is  so  infrequent,  while 
in  a  simple  gastric  ulcer  haematemesis  occurs  in  about  71  per  cent, 
of  the  cases  and  is  the  immediate  cause  of  death  in  18  per  cent, 
of  the  fatal  cases.     A  consideration  of  the  pathology  of  the  two 
diseases,    however,  at    once    explains   this   apparent  anomal}T. 
Simple  ulcer  is  a  strictly  local  affection,  and  the  tissues  which 
surround  the  area  of  necrosis  remain  in  a  comparatively  healthy 
state,  so  that  when  a  large  vessel  is  involved  by  the  disease  the 
erosion    of    its  wall   is  followed   by   severe   haemorrhage.      A 
cancerous  growth,   on  the  other  hand,  not  only  destroys  the 
smaller  vessels  which  lie  in  its  course,  but  by  invading  the  walls 
of   the    arteries  gives   rise  to    thrombosis    of    their    contained 
blood.     It  consequently  happens  that   the  arterioles   exposed 
by  the  ulcerative  process  are  already  obliterated  ;  indeed,  it  is 
only  in  cases  of  rapid  and  extensive  sloughing  that  the  destruc- 
tion of  tissue  extends  beyond  the  area  of  protection. 

5.  Perforation  of  the  Stomach 

Perforation  of  the  coats  of  the  stomach  is  a  frequent  result 
of  a  cancerous  growth,  but  its  effects  vary  considerably  under 
different  conditions.  If  no  adhesions  have  previously  formed 
around  the  base  of  the  disease,  the  contents  of  the  viscus  will 
find  their  way  into  the  general  cavity  of  the  peritoneum  and 
set  up  a  diffuse  suppurative  inflammation.     On  the  other  hand, 


THE   SEQUELS  OE  CAECINOMA  45 

if  adhesions  are  present,  the  inflammation  may  be  strictly  cir- 
cumscribed, and  a  localised  abscess  will  develop  instead  of 
general  peritonitis.  Lastly,  should  the  base  of  the  disease  be 
adherent  to  some  neighbouring  organ,  like  the  liver,  pancreas,  or 
colon,  the  result  will  be  an  infiltration  and  destruction  of  the 
tissues  of  the  viscus  secondarily  affected,  with  perhaps  the 
production  of  a  gangrenous  cavity  in  its  substance  or  the 
establishment  of  a  fistula. 

A.    ACUTE    GENEBAL    PERITONITIS 

This  result  of  perforation  is  a  comparatively  rare  cause  of 
death  in  cancer  of  the  stomach.  Brinton  noted  its  occurrence 
only  in  seventeen  out  of  507  cases,  or  in  3*3  percent. ;  Lange  in 
twelve  out  of  290  cases,  or  5'7  per  cent. ;  while  in  our  own  series 
of  265  cases  it  was  observed  six  times,  or  in  2*3  per  cent.  It  would 
thus  appear  that  out  of  a  total  of  1,062  cases  fatal  perforation 
occurred  in  thirty-five,  or  about  3  per  cent.  The  usual  site  of 
the  lesion  is  the  pyloric  end  of  the  organ,  near  the  lesser  cur- 
vature and  on  the  posterior  surface.  It  is  most  frequent  in 
medullary  carcinoma  and  in  soft  growths  of  the  cylinder-celled 
variety,  since  both  penetrate  deeply  into  the  gastric  tissues  and 
are  prone  to  undergo  rapid  ulceration.  In  scirrhus  complete 
perforation  is  rarely  observed,  while  in  diffuse  colloid  it  is 
almost  unknown  (Ellett).  The  actual  perforation  is  usually 
inconspicuous,  and  often  resembles  a  small  ragged  fissure,  but 
occasionally  it  appears  as  an  oval  or  circular  hole  with  gan- 
grenous edges  and  of  considerable  size.  Ulceration  of  a  large 
area  of  the  stomach  may  lead  to  perforation  of  its  coats  at 
several  places.  In  such  cases  it  is  usually  found  that  only  one 
ulcer  has  communicated  directly  with  the  general  cavity  of  the 
peritoneum  ;  but  Zuccarelli  has  recorded  an  instance  in  which 
several  perforations  occurred  simultaneously. 

B.    PEBIGASTBIC    ABSCESS 

A  localised  abscess  may  occur  under  three  conditions  :  (1)  If 
adhesions  have  previously  formed  around  the  base  of  the  dis- 
ease in  such  a  manner  as  to  prevent  extravasation  of  the  gas- 
tric contents  into  the  general  cavity  of  the  peritoneum ;  (2)  if 
the  initial  leakage  is  so  slight  as  to  cause  a  strictly  localised 
peritonitis,  which  in  its  turn  helps  to  circumscribe  the  products 
of  inflammation;  (3)  if  the  perforation  occurs  in  localities 
which    are  outside  the  peritoneum,  as,  for  instance,  between 


46 


CANCEE   OF  THE   STOMACH 


the  layers  of  the  lesser  omentum,  in  the  lesser  cavity  of  the 
peritoneum,  the  orifice  of  which  (foramen  of  Winslow)  has 
been  previously  obliterated,  or  in  the  substance  of  some  solid 
organ  in  the  neighbourhood. 

Frequency. — About  10  per  cent,  of  all  cases  of  perigastric 
abscess  arise  from  malignant  disease  of  the  stomach  or  duo- 
denum ;  but  its  exact  frequency  in  gastric  cancer  is  difficult 
to  determine,  since  the  majority  of  writers  merely  refer  to  the 
fact  of  its  occurrence  without  offering  any  statistical  evidence. 
Brinton  found  that  an  intraperitoneal  abscess  was  present 
in  four  out  of  507  cases  (0*8  per  cent.),  and  a  similar  condi- 


FlG. 


25. — A  medullary  growth  which  had  sloughed  and  produced  perforation 
of  the  stomach.     (Museum  of  the  Royal  College  of  Surgeons.) 


tion  was  observed  eight  times  in  our  own  series  of  265 
autopsies,  or  in  3  per  cent.  On  the  other  hand,  Osier  and 
McCrae  noted  its  existence  in  three  out  of  their  forty-six  cases. 
It  probably  occurs  in  3  to  5  per  cent,  of  all  cases  of  gastric 
carcinoma. 

Position  and  Boundaries. — The  formation  of  an  abscess  is 
a  late  phenomenon  in  gastric  cancer.  It  usually  arises  in  con- 
nection with  a  growth  which  has  destroyed  the  posterior  wall 
of  the  viscus  near  its  upper  margin,  and  its  sac  is  then  formed  by 
adhesions  between  the  under  surface  of  the  liver  and  the  stomach. 
Less  frequently  perforation  takes  place  into  the  lesser  cavity  of 
the  peritoneum,  and  the  resulting  abscess  is  bounded  in  front 


THE   SEQUELS  OF  CAECINOMA  47 

by  the  stomach,  behind  by  the  pancreas,  above  by  the  liver, 
and  below  by  the  colon  and  transverse  mesocolon.  In  such 
cases  the  pus  may  find  its  way  into  the  duodenum  or  the  colon, 
or  make  its  way  upwards  towards  the  surface  of  the  liver. 
Next  in  order  of  frequency  is  the  formation  of  an  abscess 
between  the  lower  border  of  the  stomach  and  the  transverse 
colon,  as  a  result  of  a  growth  of  the  great  curvature.  In  this 
condition  the  area  of  suppuration  is  strictly  limited  by 
adhesions  between  the  two  organs,  and  the  sac  often  discharges 
its  contents  into  the  large  bowel.  When  perforation  of  the 
anterior  wall  of  the  stomach  gives  rise  to  an  abscess,  the  latter 
is  bounded  in  front  by  the  abdominal  parietes  ;  behind  by  the 
stomach,  the  small  omentum,  and  perhaps  the  colon  ;  above 
by  the  liver ;  and  below  by  adhesions  between  the  intestines 
and  the  wall  of  the  abdomen.  In  these  cases  the  pus  exhibits 
a  tendency  to  follow  the  course  of  the  round  ligament,  and  not 
infrequently  points  at  the  umbilicus  ;  less  commonly  it  tracks 
along  the  sides  of  the  gall-bladder  towards  the  upper  surface  of 
the  right  lobe  of  the  liver.  In  rare  instances  the  sac  ruptures 
and  general  peritonitis  ensues.  Subdiaphragmatic  suppuration 
upon  the  left  side  is  very  rare  in  cancer,  and  is  chiefly 
encountered  in  disease  of  the  lesser  curvature  close  to  the 
cardiac  orifice.  As  a  rule  the  abscess  is  quite  small,  and  its 
walls  are  formed  by  adhesions  in  the  immediate  vicinity  of  the 
disease  ;  but  when  perforation  has  occurred  from  the  sudden 
sloughing  of  the  growth,  the  resulting  abscess  may  closely 
resemble  that  which  ensues  from  a  simple  ulcer  in  the  same 
situation.  In  this  position  its  boundaries  are  remarkably 
uniform.  Above  it  is  limited  by  the  left  wing  of  the 
diaphragm ;  below  by  the  upper  surface  of  the  left  lobe  of  the 
liver,  and  by  adhesions  between  the  anterior  wall  of  the 
stomach  and  the  abdominal  parietes ;  on  the  right  by  the 
falciform  ligament  ;  on  the  left  by  the  spleen,  the  gastro- 
splenic  omentum,  and  by  adhesions  between  the  cardiac  end  of 
the  stomach,  spleen,  and  diaphragm ;  and  in  front  by  the 
abdominal  wall  and  the  diaphragm. 

In  only  about  one-quarter  of  the  cases  can  any  direct  com- 
munication be  found  between  the  stomach  and  the  abscess,  and 
in  such  the  perforation  often  involves  a  large  area  of  the  gastric 
wall.  In  the  rest  the  aperture  has  usually  been  closed  before 
death  by  proliferation  of  the  growth  or  by  the  formation  of 


48'  CANCBE  OF  THE   STOMACH 

adhesions.  It  is  also  possible  that  in  some  instances  the 
leakage  really  took  place  through  the  spongy  substance  of  the 
tumour  without  anj^  actual  solution  of  continuity.  When  the 
abscess  is  small  in  size,  its  contents  usually  consist  of  thin  curdy 
pns ;  but  in  the  larger  varieties,  and  in  those  associated  with 
sloughing  of  the  gastric  wall,  the  inner  surface  of  the  sac  is  often 
invaded  by  the  neoplasm,  and  the  ichorous  fluid  it  contains 
is  mixed  with  tags  of  gangrenous  tissue  and  decomposing  food. 
Complications. — Owing  to  its  comparatively  small  size,  its 
distance  from  the  diaphragm,  and  the  low  vitality  of  the  patient, 
a  perigastric  abscess  due  to  cancer  is  seldom  accompanied  by 
any  notable  symptoms.  When  it  is  encysted  behind  the 
stomach,  the  principal  indication  of  its  presence  is  the  develop- 
ment of  intermittent  pyrexia,  accompanied  by  a  rapid  increase 
of  the  general  debility ;  but  should  the  pus  come  into  contact 
with  the  diaphragm,  it  may  set  up  suppurative  inflamma- 
tion of  the  pleura  or  pericardium.  If  the  abscess  is  situated 
anteriorly,  it  may  discharge  itself  at  the  umbilicus  or  burst  into 
the  colon  or  duodenum  ;  while  in  rare  instances  it  ruptures  into 
the  cavity  of  the  peritoneum.  Perforation  of  the  diaphragm, 
such  as  occurs  in  other  varieties,  has  never  been  recorded. 


6.  Perforation  of  Neighbouring  Organs 

A.    THE    SOLID    VISCEEA 

Perigastric  adhesions  are  a  frequent  cause  of  the  extension 
of:  malignant  disease  to  neighbouring  tissues,  and  it  is  by  no 
means  rare  to  find  a  large  secondary  tumour  in  the  substance 
of  a  solid  viscus  immediately  contiguous  to  the  cancerous  ulcer. 
Should  the  latter  have  perforated  the  whole  thickness  of  the 
gastric  wall,  the  process  of  sloughing  or  disintegration  often 
spreads  to  the  more  recent  deposit,  with  the  result  that  a  cavity 
forms  in  its  centre  which  communicates  directly  with  the 
stomach.  This  condition  is  most  common  in  connection'  with 
soft  growths  of  the  lesser  curvature,  and  owing  to  the  size  and 
close  proximity  of  the  liver  it  usually  affects  the  right  hepatic 
lobe.  The  cavity  itself  varies  from  the  size  of  a  walnut  to  that 
of  an  orange,  and  possesses  highly  vascular  walls,  which  are 
covered  with  nodular  or  fungoid  masses.  Occasionally  a  short 
sinus  connects  the  stomach  with  the  hepatic  abscess ;  while  in 


THE   SEQUELAE  OF  CAECINOMA  49 

rare  instances  the  fusion  of  several  secondary  deposits  gives 
rise  to  a  multilocular  cavity  in  the  liver,  which  communicates 
with  the  stomach  by  two  or  more  openings.  In  those  cases 
where  the  neoplasm  is  situated  close  to  the  cardiac  orifice  the 
left  lobe  of  the  liver  is  more  often  affected  than  the  right. 

The  frequent  invasion  of  the  gall-bladder  by  growths  of  the 
pylorus  usually  leads  to  its  complete  destruction.  Occasionally, 
however,  when  bilious  obstruction  has  previously  arisen  from 
pressure  upon  the  common  duct,  subsequent  perforation  of  the 
gall-bladder  gives  rise  to  the  formation  of  a  gastro-biliary 
fistula,  but  this  condition  rarely  persists. 

Implication  of  the  pancreas,  with  the  production  of  a  cavity 
in  its  substance,  is  usually  associated  with  a  primary  growth  of  the 
posterior  wall  of  the  stomach.  Sometimes  large  pieces  of  the 
gland  slough  off  and  are  found  in  the  stomach  or  in  the  sac  of 
the  abscess  ;  or  the  whole  thickness  of  the  organ  is  destroyed  and 
the  malignant  disease  invades  the  vertebral  column. 

Owing  to  the  infrequency  of  cancer  at  the  fundus,  the  spleen 
is  rarely  destroyed  by  a  primary  growth  of  the  stomach,  and  in 
only  one  of  our  cases  (04  per  cent.)  did  it  contain  an  abscess 
which  communicated  with  an  aperture  in  the  gastric  wall.  In 
one  instance  a  growth  of  the  pylorus  was  found  to  have  pro- 
duced a  sloughing  cavity  in  the  tissue  of  the  uterus,  to  which  it 
had  become  adherent.  Eenal  abscess  is  very  rare  and  almost 
exclusively  met  with  on  the  right  side. 

B.    PERFORATION    OF    THE    BOWEL — INTERNAL    GASTRIC 
FISTULA 

(1)  Gastro-colic  Fistula. — This  constitutes  the  most  com- 
mon form  of  internal  fistula.  Brinton  noted  its  existence  in 
eleven  out  of  the  507  cases  of  gastric  cancer  which  he  collected 
(2-17  per  cent.),  while  Dittrich  estimated  its  frequency  at  3*75 
per  cent,  and  Lange  at  3-8  per  cent.  Out  of  1,142  cases  of 
gastric  cancer,  including  265  of  our  own,  we  find  that  a  fistulous 
communication  existed  between  the  stomach  and  the  colon  in 
thirty,  or  in  2'5  per  cent.  In  almost  every  instance  the  primary 
growth  was  situated  at  the  lower  border  of  the  stomach,  near 
the  pylorus,  but  Lyon  has  recorded  a  case  in  which  it  occupied 
the  lesser  curvature,  and  in  one  of  our  own  series  the  anterior 
wall  of  the  fundus  was  affected.  With  regard  to  its  mode  of 
formation,  it  would  appear  that  the  fistula  may  arise  in  three 

E 


50  CANCEE  OF  THE   STOMACH 

ways.  In  the  majority  of  cases  the  neoplasia  attacks  the  bowel 
by  direct  extension,  the  two  viscera  having  become  previously 
united  by  adhesions.  Less  frequently  a  large  growth  forms 
between  the  stomach  and  the  bowel,  and  subsequently  in- 
filtrates and  destroys  the  contiguous  portions  of  the  two 
organs.  In  such  the  opening  is  usually  found  on  the  posterior 
aspect  of  the  stomach  and  at  the  upper  margin  or  on  the  anterior 
surface  of  the  colon,  while  an  irregular  sloughing  cavity  inter- 
venes between  the  two.  Lastly,  the  gastric  disease  may  set  up 
a  localised  abscess,  either  within  the  lesser  sac  of  the  peritoneum 
or  between  the  great  curvature  and  the  transverse  colon,  which 
subsequently  bursts  into  the  bowel.  In  this  latter  variety 
secondary  openings  may  occur  in  other  directions,  and  fistulous 
communications  be  established  not  only  with  the  colon,  but 
also  with  the  duodenum,  jejunum,  or  the  umbilicus. 

(2)  Gastro -intestinal  Fistula. — An  abnormal  communica- 
tion between  the  stomach  and  the  small  intestine  is  much  less 
frequent  than  the  preceding.  Brinton  observed  it  only  once 
among  his  507  cases,  but  three  examples  occur  in  our  own 
series.  It  is  chiefly  met  with  in  cases  where  the  stomach  has 
been  partially  dislocated  and  the  pylorus  has  contracted  ad- 
hesions with  the  small  bowel.  The  perforation  of  the  gut 
is  almost  always  the  result  of  direct  invasion  of  its  walls,  and 
the  jejunum  is  usually  affected.  When  the  fistula  results  from 
the  rupture  of  a  perigastric  abscess  a  secondary  communica- 
tion with  the  colon  is  apt  to  occur.  In  those  exceptional  cases 
where  the  diseased  pylorus  occupies  the  cavity  of  the  pelvis  a 
fistula  may  be  established  with  the  ileum,  ca?cmn,  sigmoid 
flexure,  or  the  rectum. 

(3)  Gastro-duodenal  Fistula. — This  variety  is  very  rare, 
and  is  usually  caused  by  perforation  of  the  posterior  wall  of  the 
stomach  close  to  the  pylorus,  whereby  asloughingcavityisformed 
behind  the  organ,  which  finally  opens  into  the  second  portion  of 
the  duodenum.  In  some  cases  the  pancreas  is  destroyed  in 
the  process,  or  a  fistulous  track  is  established  through  its  sub- 
stance (Foville).  A  secondary  communication  with  the  colon 
is  not  infrequent  (Mailliot).  Occasionally  the  pyloric  growth 
directly  invades  the  wall  of  the  bowel,  and  should  the  disease 
also  involve  the  colon,  the  contents  of  the  duodenum  will 
pass  into  the  large  intestine  through  the  intermediate  stomach 
(Osier). 


THE   SEQUELAE  OF  CAECINOMA  51 

(•A)  Bigastric  Fistula. — This  occasionally  results  from  an 
ulcerating  growth  of  the  cardiac  end  of  the  stomach  which  has 
contracted  adhesions  with  the  upper  part  of  the  pylorus. 
Kinking  and  obstruction  of  the  first  part  of  the  duodenum 
usually  accompany  this  condition,  and  occasionally  the  in- 
volvement of  the  bowel  by  the  disease  leads  to  the  establish- 
ment of  a  gastro-duodenal  fistula. 

C.    PERFORATION    OF    THE    DIAPHRAGM 

This  must  be  an  extremely  rare  event,  since  it  was  not  ob- 
served in  the  course  of  1,850  necropsies  upon  cancer  of  the 
stomach,  nor  have  we  been  able  to  find  a  single  authentic 
example  of  it  in  the  literature  upon  the  subject.  Its  infrequency 
may  be  explained  partly  by  the  fact  that  the  vicinity  of  the 
cardiac  orifice,  which  is  the  only  region  of  the  stomach  where 
the  accident  could  take  place,  is  very  seldom  the  site  of  perfora- 
tion, and.  partly  by  the  rapidity  with  which  disease  in  this 
position  tends  to  produce  fatal  inanition.  When  the  malignant 
growth  extends  into  the  oesophagus,  it  occasionally  perforates 
the  wall  of  that  tube  and  lays  open  the  left  pleural  cavity  or  the 
posterior  mediastinum. 

D.    PERFORATION    OF    THE    SKIN — EXTERNAL    GASTRIC 

FISTULA 

This  variety  would  seem  to  be  even  less,  frequent  in  cancer 
than  in  ulcer  of  the  stomach,  since  out  of  the  twenty-eight 
cases  of  gastro-cutaneous  fistula  collected  by  Murchison,  twelve 
were  due  to  the  simple  and  only  six  to  malignant  disease. 
Moreover,  the  records  of  1,142  necropsies  upon  cancer  of  the 
stomach  contain  only  three  instances  of  external  fistula  (0*26 
per  cent.),  while  a  careful  search  through  the  literature  reveals 
only  nineteen  examples  of  this  affection.  In  those  cases 
where  the  fistula  was  established  spontaneously  it  was  usually 
situated  at  the  umbilicus,  but  when  it  resulted  from  surgical 
interference  it  was  sometimes  located  in  the  epigastrium  or  in 
the  left  hypochondrium.  In  the  majority  only  one  sinus 
existed,  but  in  the  case  reported  by  Murchison  there  were  two, 
while  in  another  there  were  several  (Coote).  The  external 
orifice  varied  considerably  in  size,  in  two  cases  being  only  large 
enough  to  admit  a  fine  probe,  while  in  the  rest  a  cannula  or 


52  CANCEE  OP  THE   STOMACH 

even  the  forefinger  could  be  inserted  into  it.  In  one  instance 
only  it  possessed  the  diameter  of  a  shilling  (Cameron).  In  every 
case  the  external  fistula  communicated  with  the  stomach 
through  the  medium  of  an  abscess  which  was  bounded  behind 
by  the  stomach,  the  left  lobe  of  the  liver,  and  the  colon,  in 
front  by  the  abdominal  wall,  and  at  the  sides  by  adhesions 
between  the  aforementioned  viscera  and  the  parietes.  In  fifteen 
out  of  seventeen  cases  the  primary  disease  was  situated  at  the 
pylorus,  which  was  usually  adherent  to  the  anterior  wall  of  the 
abdomen,  while  in  the  other  two  the  growth  affected  one  or 
other  curvature.  An  obvious  perforation  of  the  stomach 
existed  in  twelve  cases,  and  was  invariably  situated  upon  the 
anterior  wall.  It  varied  in  size  from  a  small  chink  to  an 
aperture  several  inches  square.  The  malignant  disease  was 
always  of  the  spheroidal-celled  type,  and  in  two  instances 
presented  colloid  changes. 

Contrast  of  Perforation  in  Cancer  with  that  in  Simple 
Ulcer. — A  simple  ulcer  is  far  more  prone  to  perforate  the  wall  of 
the  stomach  than  a  cancerous  growth.  According  to  our 
clinical  statistics  this  accident  occurs  in  7  per  cent,  of  all 
chronic  ulcers,1  but  only  in  3  per  cent,  of  the  cases  of  malig- 
nant disease.  The  disproportionate  tendency  to  perforation 
which  is  thus  exhibited  by  the  simple  disease  is  further 
emphasised  when  post-mortem  evidence  is  solely  relied  upon, 
for  we  found  that  out  of  678  necropsies  in  which  an  open 
ulcer  was  present,  perforation  with  general  peritonitis  had 
taken  place  in  153,  or  in  22-5  per  cent.,  while  in  1,062  fatal 
cases  of  gastric  cancer  a  similar  condition  existed  only  in  thirty- 
three,  or  in  3  per  cent.  Consequently,  as  a  cause  of  death, 
perforation  is  more  than  seven  times  as  frequent  in  ulcer  as  in 
cancer.  The  explanation  of  this  phenomenon  is  to  be  found 
in  the  different  pathology  of  the  two  complaints.  In  simple 
ulcer  the  necrotic  process  is  limited  to  a  small  area  of  the  gastric 
wall,  and  any  peritonitis  that  may  develop  around  the  base  of 
the  disease  is  strictly  circumscribed.  It  therefore  happens  that 
by  the  time  the  peritoneum  is  exposed  the  sole  obstacle  to 
perforation  lies  in  the  fortuitous  adhesion  of  some  contiguous 
organ.  A  malignant  growth,  on  the  other  hand,  is  usually 
attended  by  extensive  adhesions  as  soon  as  the  muscular  coat 

1   Ulcer  of  the  Stomach  and  Duodenum,  p.  200.     This  estimate  includes  scars 
as  well  as  open  ulcers. 


THE   SEQUELS  OF  CAECINOMA  53 

has  become  involved,  while,  pari  passu  with  the  loss  of  sub- 
stance internally,  the  base  of  the  ulcer  is  thickened  by  the 
growth  of  fresh  material.  Indeed,  it  is  only  when  rapid 
sloughing  occurs  and  the  process  of  destruction  outruns  that 
of  repair  that  the  danger  of  perforation  becomes  imminent. 

The  seat  of  election  of  the  two  diseases  also  exerts  an 
important  influence  upon  their  respective  proclivity  to  perfora- 
tion. An  ulcer  affects  the  anterior  wall  in  about  8  per  cent, 
of  all  cases  in  which  it  occurs,  but  in  cancer  the  percentage 
incidence  of  the  growth  in  this  position  does  not  exceed  2  ;  and 
since  this  part  of  the  stomach  is  more  liable  to  perforation  than 
any  other,  owing  to  the  almost  invariable  absence  of  protective 
adhesions,  it  follows  that  the  accident  must  be  most  frequent 
in  the  simple  complaint.  For  a  similar  reason  general  peri- 
tonitis is  the  usual  result  of  the  perforation  of  the  stomach  by  a 
simple  ulcer,  while  in  carcinoma  a  localised  abscess  develops  in 
about  one-third  of  the  cases.  With  regard  to  the  establishment 
of  internal  fistulse,  it  is  worthy  of  note  that  a  gastro-colic  fistula 
is  twice  as  frequent  in  cancer  as  in  ulcer,  and  that  abnormal 
communications  between  the  stomach  and  other  parts  of  the  in- 
testinal tract  are  practically  confined  to  the  malignant  com- 
plaint. On  the  other  hand,  the  more  frequent  incidence  of 
simple  u]cer  upon  the  anterior  wall  of  the  viscus  renders  this 
disease  far  more  liable  to  produce  an  external  fistula,  and  also 
permits  the  occasional  perforation  of  the  diaphragm. 


7.  Invasion  of  other  Viscera  and  Secondary  Growths 

Carcinoma  of  the  stomach  often  exhibits  an  extreme  degree  of 
malignancy,  and  almost  always  extends  beyond  the  confines  of 
the  organ  before  death.  As  the  result  of  Brinton's  researches  it 
is  usually  taught  that  secondary  deposits  occur  in  about  50  per 
cent,  of  all  cases,  although  Welch  concluded  from  a  study  of 
much  larger  statistics  that  they  are  present  in  at  least  63  per 
cent.1  These  and  other  similar  figures,  however,  only  refer  to 
such  growths  of  a  metastatic  character  as  were  visible  to  the 
naked  eye,  and  do  not  indicate  in  any  way  the  frequency  with 
which  the  disease  had  invaded  the  lymphatic  vessels  outside 

1  It  is  noteworthy  that  modern  writers  give  a  much  higher  percentage  of 
secondary  growths,  viz.  Ewald  75,  Perry  and  Shaw  80,  and  Osier  and  McCrae  86. 


54  CANCEE  OF  THE   STOMACH 

the  stomach,  and  had  produced  a  very  real,  though  perhaps  an 
invisible,  infection  of  the  neighbouring  viscera. 

That  extensive  dissemination  usually  occurs  even  in  cases 
•which  present  no  obvious  metastases  is  readily  proved  by  a 
microscopical  examination,  for  it  is  found  that  not  only  the 
stomach  itself  at  some  distance  from  the  disease,  but  the 
perigastric  lymphatic  glands,  the  omenta  and  peritoneal  aspect 
of  the  diaphragm,  present  numerous  groups  of  cells  which  are 
identical  in  character  with  those  of  the  original  tumour.  It  is 
also  the  unhappy  experience  of  most  surgeons  wTho  have  been 
tempted  to  extirpate  an  apparently  localised  and  uncomplicated 
growth  of  the  pylorus,  to  find  that  within  a  comparatively  short 
time  a  recurrence  occurred  in  one  or  other  of  these  situations. 
We  are  consequently  led  to  infer  that  almost  from  its  commence- 
ment the  neoplasm  tends  to  infect  the  submucous  tissue  for  a 
considerable  distance  around  its  centre  of  activity,  and  that 
within  the  course  of  a  few  weeks  some  of  its  epithelial  elements 
gain  access  to  the  lymphatic  system. 

But  although  a  visible  extension  of  the  disease  to  the 
surrounding  viscera  constitutes  a  very  crude  indication  of  its 
distribution,  the  presence  of  secondary  deposits  is  of  consider- 
able importance  from  a  clinical  standpoint,  since  they  not  only 
give  rise  to  important  physical  signs,  but  exert  a  marked  in- 
fluence upon  the  duration  of  the  complaint.  It  is  therefore 
convenient  to  determine  as  far  as  possible  their  relative 
frequency  in  different  organs,  and  the  means  by  wmich  the 
diffusion  of  the  cancer  cells  is  effected. 

Out  of  131  cases  of  gastric  cancer  in  which  all  the  organs  of 
the  body  were  carefully  examined,  we  find  that  the  grow7th  had 
extended  beyond  the  wralls  of  the  stomach  in  113,  or  in  86  per 
cent.  The  following  table  showTs  the  percentage  frequency 
with  which  the  various  tissues  were  affected,  and  also  affords 
a  contrast  with  the  conclusions  formed  by  "Welch  and  Lebert. 

It  will  be  observed  that  in  several  respects  our  conclusions 
differ  materially  from  those  arrived  at  by  other  writers.  In 
the  first  place,  the  percentage  frequency  of  glandular  infection 
is  twice  as  great  as  that  usually  accepted.  This  may  be  ex- 
plained partly  by  the  difficulty  of  detecting  a  few  small  glands 
among  a  mass  of  adhesions  unless  a  special  search  is  made  for 
them,  and  partly  by  the  fact  that  many  morbid  anatomists 
allow  the  existence  of  disease  only  when  the  glands  exhibit 


THE   SEQUELS  OF  CAECINOMA 


oo 


Table  6. — An   Analysis   of   131    Cases  of   Gastric  Cancer,  showing   the    Fre- 
quency  WITH    WHICH  THE   VARIOUS    OTHER    ORGANS   WERE    AFFECTED   BY   THE    DISEASE 


Organ 

1 
Xo.  of 
cases 

Percentage 

Welch 

Lebert 

Lymphatic    glands     (en 

larged) 

104 

79-4 

35     % 

54-5% 

Liver  '     . 

65 

50 

30-2% 

40-9% 

Peritoneum  (and  omenta 

46 

35 

) 

37-5% 

Small  intestine 

2 

1-5 

22-7% 

;-    io  2% 

Large  intestine 

8 

6 

J 

Pancreas 

25 

19 

7-8% 

7    % 

Kidney    . 

5 

3-7 

— 

}         8    % 

Adrenals 

3 

2-3 

— 

Spleen     . 

5 

3-7 

1-7% 

5-7% 

Pleura 

6 

4-5 

6-2% 

8-3% 

Lungs 

10 

7-6 

Heart 

3 

23 

— 

6    % 

( +  pericardium) 

Uterus     . 

2 

15 

— 

4-5% 

Ovary 

3 

23 

- 

Bladder  . 

2 

1-5 

— 

— 

Bones 

2 

1-5 

— 

3-5% 

Brain 

1 

•7 

•6% 

4-5% 

Skin 

3 

2-3 

— 

3    % 

Supraclavicular  glands 

4 

3 

— 

— 

Mediastinal  glands 

14 

10-6 

— 



visible  nodules  of  growth.  Since,  however,  we  have  found  that 
every  swollen  gland  in  the  vicinity  of  a  cancerous  stomach  shows 
signs  of  infection  when  examined  by  the  microscope,  we  prefer 
to  regard  any  enlargement  which  is  apparent  to  the  naked 
eye  as  indicative  of  disease. 

In  the  second  place,  the  liver  and  pancreas  appear  to  be 
unduly  affected  in  our  cases,  because  we  have  recorded  every 
instance  in  which  they  were  involved  by  the  growth,  instead  of 
drawing  a  distinction  between  invasions  by  contiguity  and  true 
metastases.  Our  reason  in  so  doing  is  to  emphasise  the  rapid 
and  widespread  dissemination  of  a  gastric  cancer,  the  im- 
portance of  which  is  apt  to  be  underrated  when  only  metastatic 
growths  are  considered  worthy  of  attention.  It  might  also  be 
urged  that  the  pathological  distinction  between  secondary 
deposits  and  direct  invasions  is  often  more  apparent  than  real. 
Thus,  in  many  cases  where  true  metastases  are  scattered 
through  the  substance  of  the  liver,  the  infection  of  the  portal 
system  may  be  shown  to  have  taken  place  through  the  medium 


1  The  exact  figures  in  this  case  were  :  multiple  discrete  tumours  =  forty-seven, 
or  35"8  per  cent. ;  direct  invasions  —  eighteen,  or  13"7  per  cent. 


56 


CANCEE   OF  THE   STOMACH 


of  a  mass  of  growth  which  had  spread  into  it  from  the  adherent 
stomach  ;  while  in  the  case  of  the  omentum  it  is  often  im- 
possible to  determine  whether  the  induration  was  primarily 
due  to  extension  by  the  lymphatics,  or  to  direct  invasion  from 
the  peritoneal  surface  of  the  growth. 

The  liability  of  the  different  organs  to  infection  varies 
with  the  situation  of  the  primary  disease  in  the  stomach.  In 
some  cases  this  chiefly  depends  upon  the  relative  proximity 
of  the  viscus  in  question  to  the  growth,  as,  for  example,  the 
invasion  of  the  pancreas  by  tumours  of  the  posterior  surface  of 
the  stomach  and  of  the  spleen  by  those  of  the  fundus.  In 
others,  however,  it  is  the  type  of  the  disease  rather  than  its 
location  which  seems  to  be  responsible  for  its  greater  in- 
fectivity.  It  will  be  seen  in  the  following  table  that  cancers 
of  the  pylorus  which  cause  constriction  of  the  orifice  com- 
paratively rarely  affect  the  liver,  for  the  reason  that  they  are 
usually  scirrhus ;  while  those  which  attack  the  body  of  the 
organ  or  the  cardia  are  particularly  destructive  of  other  tissues, 
because  they  so  often  possess  a  medullary  or  cylindrical-cell 
structure.  Lastly,  it  will  be  noticed  that  the  peritoneum  is 
exceptionally  prone  to  suffer  when  the  whole  or  greater  part  of 
the  gastric  wall  is  invaded  by  the  disease. 


Table  7. 


-Relative  Frequency  of  Metastases  in  Cancer  of  different 
Regions  of  the  Stomach 


Situation  of  disease 


Glands 
Liver    . 
Peritoneum 
Pancreas 
Lungs  . 
Pleura  . 
Spleen  . 
Kidneys 


Pylorus 

Pylorus 

(with 
stenosis) 

(without 
stenosis) 

curvatures 

60% 

85% 

93% 

24% 

64% 

70% 

30% 

36% 

26% 

18% 

14% 

30% 

3-7% 

6% 

13% 

3-7% 

6% 

4% 

— 

3% 

4% 

1-9% 

4% 

4% 

"Whole  or 

Cardia 

greater  part 

of  organ 

89% 

87% 

84% 

37% 

46% 

75% 

7% 

25% 

7% 

9% 

7% 

25% 

14% 

6% 

14% 

1% 

Carcinoma  of  the  stomach  may  lead  to  the  invasion  of 
other  viscera  in  several  different  ways,  viz.,  by  direct  extension 
into  the  surrounding  tissues  ;  by  infection  of  the  lymphatic  and 
blood  streams  ;  by  the  detachment  of  small  particles,  and  their 
subsequent  transplantation  upon  serous  or  mucous  surfaces ; 
or  by  local  contact. 


THE   SEQUELS  OP  CAECINOMA  57 

A.     DIEECT    INVASION 

The  fact  that  a  morbid  growth  invariably  invades  the 
submucous  tissue  for  some  distance  beyond  its  apparent  con- 
fines suggests  that  it  would  frequently  extend  by  continuity 
into  the  oesophagus  or  duodenum.  As  a  matter  of  fact,  how- 
ever, such  a  process  is  comparatively  rare  as  compared  with  the 
invasion  of  merely  contiguous  structures.  Thus,  out  of  the 
131  cases  already  referred  to,  we  find  that  the  pancreas  was 
directly  invaded  in  twenty-two,  or  16-7  per  cent.  ;  the  liver 
in  eighteen,  or  13-7  per  cent. ;  the  colon  in  seven,  or  5*3  per 
cent. ;  the  spleen  in  five,  or  3-7  per  cent. ;  the  oesophagus  in  eight, 
or  45  per  cent.  ;  and  the  duodenum  in  two,  or  1*5  per  cent.  The 
preference  thus  exhibited  to  invasion  via  the  peritoneum  pro- 
bably depends  upon  the  peculiar  facilities  which  the  latter 
affords,  by  its  extensive  system  of  lymphatics  and  by  the 
numerous  bridges  which  exist,  in  the  form  of  fibrinous  adhesions, 
for  the  transference  of  cancer  cells  from  one  organ  to  the  other. 
The  exceptional  liability  of  the  pancreas  is  probably  the  result 
of  three  allied  conditions.  In  the  first  place,  its  situation 
immediately  behind  the  stomach  not  only  brings  it  into  close 
contact  with  almost  every  growth  which  affects  that  viscus,  but 
also  with  those  species  (medullary  and  adeno-carcinomata) 
which  possess  the  greatest  degree  of  malignancy.  Again,  the 
firm  structure  of  the  gland  and  its  fixed  position  greatly  con- 
duce to  the  formation  of  adhesions  and  to  their  subsequent 
invasion  by  the  disease.  Finally,  the  close  proximity  of  the 
coeliac  glands  and  of  the  great  lymphatic  vessels  which  drain 
the  lower  half  of  the  stomach  must  always  be  a  source  of  con- 
siderable danger  to  the  organ. 

The  situation  of  the  liver  renders  it  less  exposed  to  direct 
invasion,  since  it  only  comes  into  contact  with  the  upper 
margin  and  a  part  of  the  anterior  surface  of  the  stomach,  while 
its  constant  movement  during  respiration  militates  against  the 
formation  of  adhesions.  These  natural  advantages  are,  how- 
ever, more  than  counterbalanced  by  its  connection  with  the  lesser 
omentum  and  the  vessels  it  contains,  since  these  constitute  a 
means  of  communication  with  the  diseased  stomach,  of  which 
the  neoplasm  only  too  often  takes  advantage. 

The  spleen  is  much  less  frequently  invaded  than  the  afore- 
mentioned organs,  owing  to  its  remote  situation  from  the  usual 


58 


CANCEE  OF  THE   STOMACH 


seat  of  disease  and  to  the  peculiar  distribution  of  the  gastric 
lymphatics.  If,  however,  only  those  cases  are  examined  in 
which  the  growth  affects  the  cardiac  end  of  the  stomach,  this 
disparity  at  once  disappears  (vide  Table  7,  p.  56).  For  a  similar 
reason  the  transverse  colon  is  only  directly  implicated  in  about 
5-3  per  cent,  of  all  cases  of  gastric  cancer,  but  in  nearly  32  per 
cent,  of  those  in  which  the  great  curvature  is  the  seat  of  the 
primary  growth.  Direct  invasion  of  the  kidney  is  very  rare ; 
but  a  similar  immunity  is  not  shared  by  the  suprarenal  glands, 
which  are  frequently  involved  (especially  the  left  one)  in  disease 
of  the  posterior  surface  of  the  stomach  and  of  the  cardia. 


Fig.  26. — A  large  growth  of  cylindrical-celled  carcinoma  at  the  pylorus,  extending 
into  the  duodenum.     (Museum  of  the  Royal  College  of  Surgeons.) 

Turning  now  to  the  question  of  invasion  by  continuity,  it  is 
at  once  obvious  that  a  great  difference  exists  between  the 
respective  liability  of  the  duodenum  and  the  oesophagus.  A 
pyloric  growth,  if  it  spreads  at  all,  almost  always  extends  in 
the  direction  of  the  body  of  the  viscus,  and  though  it  may 
actually  project  into  the  lumen  of  the  duodenum,  but  rarely 
implicates  its  walls.  Lebert  observed  one  exception  to  this 
rule  in  the  course  of  thirty-four  necropsies  upon  cancer  of  the 
pylorus,  Brinton  ten  in  125,  and  ourselves  two  in  eighty-seven. 
Thus,  out  of  a  total  of  246  cases,  a  pyloric  growth  involved  the 
duodenum  in  only  thirteen,  or  5*2  per  cent.     It  also  seems  that 


THE   SEQUELS  OF  CAECINOMA 


59 


t« 


the  cylinder-cell  variety  rnore  often  affects  the  bowel  than  the 
other  forms. 

On  the  other  hand,  the  natural  tendency  for  a  cancer  of  the 
cardia   is    to    spread 

into  the  walls  of  the  «;-  \  ■,  :Wr^% 

oesophagus.       When  j§'  \ 

the    disease  develops  P.. 

in     the      immediate  ,"  .  U 

vicinity  of  the  orifice, 
this  mode  of  exten- 
sion probably  occurs 
in  every  case  (Boki- 
tansky)  ;  but  when  it 
primarily  implicates 
the  walls  or  curva- 
tures at  some  distance 
from  the  aperture,  we 
find  that  invasion 
of  the  oesophagus 
takes  place  only  in 
about  one-half  of  the 
cases  (46  per  cent.). 

The  notable  differ- 
ence which  is  thus 
observed  in  the  spread 
of  a  neoplasm  at 
opposite  ends  of  the 
organ  is  best  ex- 
plained by  contrast- 
ing the  mode  of 
insertion  of  the  oeso- 
phagus into  the 
stomach  with  that  of 
the  pylorus  into  the 
duodenum.  In  the 
former  case  the  sub- 
mucous and  muscular 
coats  of  the  two 
viscera  are   perfectly 

continuous,  and  there      FlG<    27-~ A  soft  spheroidal-celled  growth    of   the 
.  cardiac    orifice   extending   up    the  oesophagus. 

IS,    consequently,    no  (London  Hospital  Museum.) 


60  CANCER  OF  THE   STOMACH 

obstacle  to  the  spread  of  a  morbid  growth  from  one  organ  to 
the  other.  The  duodenum,  on  the  other  hand,  is  attached  to 
the  pylorus  much  in  the  same  way  as  the  vagina  embraces  the 
neck  of  the  uterus,  the  submucous  and  the  inner  and  muscular 
coats  of  the  two  viscera  along  the  line  of  fusion  being  so 
distinct  from  one  another  that  direct  continuity  can  scarcely  be 
said  to  exist.  It  consequently  happens  that  a  growth  of  the 
pylorus  is  more  apt  to  infiltrate  the  contiguous  walls  of  the 
stomach  than  to  extend  obliquely  along  a  comparatively  thin 
and  external  layer  of  tissue  into  the  wall  of  the  bowel.  It  is  also 
probable  that  the  lymphatic  vessels  of  the  pylorus,  by  pursuing 
a  course  away  from  the  bowel  towards  the  cardia  or  the 
pancreas,  also  tend  to  promote  extension  of  the  disease  in  an 
opposite  direction  to  the  duodenum. 

The  appearances  presented  by  the  organs  directly  invaded 
by  carcinoma  vary  considerably  in  different  cases.  When  the 
pancreas  is  affected  the  whole  or  greater  portion  of  the  gland  is 
usually  destroyed ;  but  in  the  case  of  the  liver  and  spleen  the 
disease  more  often  takes  the  form  of  a  globular  or  wedge- 
shaped  mass,  which  extends  only  a  short  distance  into  their 
interior,  but  is  accompanied  by  great  infiltration  of  the  sub- 
serous tissue  and  lymphatic  glands.  Extension  to  the  colon 
takes  place  through  the  medium  of  the  gastro-colic  omentum 
and  newly  formed  adhesions,  and  not  infrequently  gives  rise 
to  a  large  mass  of  growth  between  the  stomach  and  the  bowel, 
which  greatly  obstructs  the  lumen  of  the  latter.  Invasion  of 
the  oesophagus  occurs  most  frequently  in  soft  spheroidal-celled 
cancers,  and  either  affects  the  entire  circumference  of  the  tube 
for  half  an  inch  or  more  above  the  cardiac  orifice,  or  produces 
an  irregular  infiltration  of  its  posterior  and  inner  wall.  This 
latter  variety  often  leads  to  perforation.  More  rarely  the  sub- 
mucous tissue  of  the  oesophagus  is  invaded  by  one  or  more 
series  of  nodules,  which  extend  for  some  distance  in  its  long 
axis  and  may  even  reach  the  pharynx  (Lazarus-Barlow). 
These  occasionally  ulcerate  and  produce  small  circular  sores. 
When  the  disease  invades  the  duodenum  it  seldom  involves 
more  than  two  inches  of  the  bowel. 


THE   SEQUELJE   OF  CAECINOMA  61 


B.    LYMPHATIC    INFECTION 

The  epithelial  offshoots  from  a  cancerous  tumour  penetrate 
the  surrounding  structures  in  the  direction  of  the  least  resistance, 
and  therefore  soon  find  their  way  into  the  spaces  in  the  con- 
nective tissue  which  constitute  the  radicles  of  the  gastric 
lymphatics.  After  gaining  an  entrance  to  the  lymph  stream 
the  cells  are  gradually  swept  onwards  until  they  are  arrested  in 
the  nearest  lymphatic  gland,  when  they  undergo  multiplication 
and  reproduce  the  structure  of  the  original  tumour.  Sub- 
sequently the  efferent  vessels  of  the  gland  become  in  their  turn 
the  means  of  transmitting  the  disease  to  its  neighbour,  and 
thus  the  process  goes  on  until  the  whole  lymphatic  system  is 
infected.  In  order  to  gain  a  clear  conception  of  the  various 
routes  by  which  such  a  generalisation  is  brought  about,  it  is 
necessary  to  bear  in  mind  the  general  arrangement  of  the 
gastric  lymphatics  and  of  those  of  the  surrounding  viscera. 

The  Lymphatics  of  the  Stomach  commence  in  the  mucous 
coat,  and  thence  follow  the  blood-vessels  to  the  subserous  tissue. 
Some  pursue  an  upward  course  towards  the  lesser  curvature, 
others  pass  downwards  to  the  greater  curvature,  while  others 
again  run  across  the  fundus  to  the  gastro-splenic  omentum. 
In  this  way  three  principal  groups  of  vessels  are  formed — the 
superior  gastric,  the  inferior  gastric,  and  those  belonging  to  the 
fundus,  or  the  left  gastric  lymphatics  as  they  are  sometimes 
called. 

The  Superior  Gastric  Lymphatics  follow  the  course  of  the 
coronary  vein  along  the  small  curvature  between  the  layers  of 
the  lesser  omentum.  After  passing  through  the  superior  gastric 
glands  they  turn  backwards  near  the  cardiac  orifice  and  enter 
the  coeliac  glands.  The  Inferior  Gastric  Lymphatics  direct 
their  course  towards  the  pylorus  in  company  with  the  right 
gastro-epiploic  vessels,  and  after  passing  through  the  inferior 
gastric  glands  and  joining  the  lymphatics  from  the  upper 
duodenum  they  pass  between  the  pylorus  and  the  pancreas  to 
the  coeliac  glands. 

The  Left  Gastric  Lymphatics  accompany  the  vasa  brevia 
between  the  folds  of  the  gastro-splenic  omentum  and  terminate 
in  the  glands  at  the  hilus  of  the  spleen.  There  are  also 
several  lymphatics  which  run  directly  from  the  pylorus  to  the 
hepatic  glands  in  the  lesser  omentum. 


62 


CANCEE  OF  THE   STOMACH 


The  Lymphatic  Glands  of  the  Stomach  consist  of  two  groups, 
the  superior  and  the  inferior. 

The  Superior  Gastric  Glands  are  usually  five  or  six  in 
number,  and  are  situated  along  the  upper  margin  of  the  organ 
between  the  layers  of  the  gastro-hepatic  omentum.  They 
receive  the  superior  gastric  lymphatics,  and  their  efferent  ducts 
pass  in  the  maimer  already  described  to  the  coeliac  glands. 

The  Inferior  Gastric  or  Gastro-epiploic  Glands,  seven  or 
eight  in  number,  lie  between  the   folds  of  the  large  omentum 


Lymphatics  of  great 
omentum 


Inferior  gastric 
elands 


Superior  gastric 
glands 


Cardiac  orifice 


Spleen 


Splenic  glands 
Fig.  28.  —  Diagram  of  the  lymphatics  oi  the  stomach.     (C.  H.  Leaf.) 

along  the  great  curvature.  They  receive  the  inferior  gastric 
lymphatics  and  also  those  of  the  omentum.  Their  efferent 
vessels  empty  themselves  into  the  coeliac  glands. 

The  Coeliac  Glands,  about  twenty  in  number,  are  clustered 
around  the  coeliac  axis  in  front  of  the  aorta  and  above  the 
origin  of  the  superior  mesenteric  artery.  They  receive  the 
efferent  vessels  of  the  superior  and  inferior  gastric,  splenic  and 
pancreatic  glands,  and  some  of  those  of  the  hepatic  glands. 
Their  ducts  join  the  intestinal  lymphatic  trunks  and  open  into 
the  receptaculum  chyli. 


THE   SEQUELS  OF  CAECINOMA  63 

The  Mesenteric  Glands  lie  between  the  layers  of  the 
mesentery,  and  number  from  one  hundred  and  fifty  to  two  hun- 
dred. Their  efferent  vessels  unite  to  form  one  or  more  trunks 
(intestinal  lymphatic  trunks),  which  after  receiving  the  efferent 
vessels  of  the  mesocolic  glands  open  with  the  ducts  of  the 
cceliac  glands  into  the  receptaculum  chyli. 

The  Sacral  and  Lumbar  Glands  are  situated  respectively 
in  the  hollow  of  the  sacrum  and  upon  the  fronts  and  sides  of 
the  lumbar  vertebrae.  Their  efferent  vessels  enter  the  recepta- 
culum chyli. 

The  Lymphatic  Vessels  of  the  Liver  consist  of  a  superficial 
and  a  deep  set.  The  former  ramify  beneath  the  peritoneal  invest- 
ment, and  partly  converge  to  the  diaphragm  and  enter  the  an- 
terior mediastinal  glands,  and  partly  towards  the  anterior  margin 
of  the  organ  on  their  way  to  the  hepatic  or  coeliac  glands.  The 
deep  vessels  accompany  the  branches  of  the  portal  and  hepatic 
veins,  and  are  directed  respectively  into  the  hepatic  glands  and 
the  receptaculum  chyli. 

The  Lymphatics  of  the  Spleen  and  the  Pancreas  usually  unite 
and  enter  the  coeliac  glands. 

The  Diaphragmatic  Lymphatics  follow  the  blood-vessels 
and  terminate  anteriorly  in  the  internal  mammary  and  anterior 
mediastinal  glands,  and  posteriorly,  in  the  posterior  mediastinal 
glands. 

The  Anterior  Mediastinal  Glands  lie  behind  the  sternum. 
They  receive  the  lymphatics  of  the  antero- median  portion  of  the 
diaphragm  and  those  from  the  convex  surface  of  the  right  lobe  of 
the  liver.  Their  efferent  ducts  pass  upwards  to  the  superior 
mediastinal  glands. 

The  Superior  Mediastinal  Glands  lie  in  front  of  the  upper 
part  of  the  pericardium,  the  arch  of  the  aorta,  and  the  left 
innominate  vein.  Their  efferent  vessels  pass  along  the  sides 
of  the  trachea  to  join  the  thoracic  duct  or  the  right  lymphatic 
duct. 

The  Posterior  Mediastinal  Glands  are  placed  in  the  pos- 
terior mediastinum  along  the  course  of  the  aorta.  They  receive 
lymphatics  from  the  oesophagus,  from  the  posterior  part  of  the 
diaphragm,  and  from  the  right  border  of  the  liver.  Their 
efferent  vessels  pass  chiefly  into  the  thoracic  duct,  but  some 
enter  the  bronchial  glands. 

The   Beceptaculum   Chyli  lies  between  the  aorta  and  the 


64 


CANCEK  OF  THE   STOMACH 


right  crus  of  the  diaphragm  upon  the  body  of  the  second 
lumbar  vertebra.  It  receives  the  efferent  vessels  of  the  lumbar 
and  cceliac  glands,  the  intestinal  lymphatic  trunks,  and  some  of 
the  hepatic  and  gastric  lymphatics.  From  it  springs  the 
thoracic  duct,  which  enters  the  thorax  by  the  aortic  opening 
of  the  diaphragm,  runs  up  the  posterior  mediastinum,  and,  leav- 
ing the  chest  at  the  superior  opening  on  the  left  side,  enters  the 
junction  of  the  left  internal  jugular  and  subclavian  veins. 


Iat.  jugular  vein 


Deep  lymphatics  of  neck 


Eight  lymphatic 
duct 


"Upper  right  inter- 
costal lymphatics 


Subclavian  vein 

Opening  of  thoracic 
duct 


Upper  left  intercostal 
lymphatics 


Intercostal  lymphatics 


Lower  right  intercostal 
lymphatics 


Lumbar  glands 


Lower  left  intercostal 
lymphatics 


Cceliac  glands 


Fig.  29. — Diagram  of  the  thoracic  duct  and  its  tributaries.     (C.  H.  Leaf.) 


This  brief  review  of  the  lymphatic  system  of  the  stomach 
and  its  principal  connections  serves  to  illustrate  three  important 
points.  In  the  first  place,  the  stomach  itself  would  seem  to  be 
naturally  divided  into  three  lymphatic  areas,  each  of  which  is 
provided  with  a  separate  set  of  glands.  The  upper  or  superior 
area  corresponds  to  the  upper  halves  of  both  surfaces  from  the 


THE   SEQUELAE  OF   CAECINOMA  65 

pylorus  to  the  junction  of  the  central  third  with  the  fundus, 
and  is  drained  by  the  vessels  which  proceed  to  the  superior 
gastric  glands.  The  inferior  area  includes  the  lower  halves  of 
the  pyloric  and  central  portions  of  the  viscus,  and  its  lymphatics 
pass  to  the  inferior  gastric  glands  ;  while  the  fundus,  or  left  area 
of  the  organ,  is  connected  with  the  glands  situated  at  the  hilus 
of  the  spleen.  In  the  second  place,  the  coeliac  glands,  by 
receiving  the  efferent  vessels  of  each  of  these  groups,  are  not 
only  liable  themselves  to  become  invaded  by  cancer  of  any  part 
of  the  stomach,  but  also  to  act  as  a  centre  for  the  distribution 
of  infection  to  the  other  lymphatic  systems  with  which  they 
are  immediately  connected.  Finally,  the  receptaculum  chyli, 
being  the  reservoir  into  which  the  coeliac  glands  pour  their 
lymph,  tends  to  infect  the  mesenteric  and  lumbar  glands 
and  the  various  tributaries  of  the  thoracic  duct.  The  superior 
gastric  glands  are  more  often  affected  than  the  other  groups, 
by  reason  of  the  abnormal  frequency  of  carcinoma  in  the 
upper  segment  of  the  stomach.  As  a  rule  every  member  of 
the  series  is  more  or  less  implicated,  but  should  the  primary 
growth  be  limited  to  the  cardiac  orifice  only  one  or  two  of  the 
nearest  may  show  signs  of  enlargement,  since  the  lymphatics  of 
this  region  pass  directly  to  the  cceliac  group.  Secondary 
carcinoma  of  the  glands  along  the  lesser  curvature  often  leads 
to  disease  of  those  in  the  portal  fissure,  which  in  their  turn 
diffuse  the  infection  through  the  superficial  lymphatics  of 
the  liver  to  the  diaphragm  and  the  pleurae.  That  this  mode  of 
extension  is  of  considerable  importance  is  shown  by  the  fact 
that  in  34  per  cent,  of  oar  cases  where  the  superior  gastric 
glands  were  diseased  miliary  growths  were  present  upon  the 
lower  surface  of  the  diaphragm. 

Carcinoma  of  the  pylorus  usually  involves  both  the  upper 
and  lower  systems  of  lymphatics,  and,  besides  giving  rise  to 
enlargement  of  the  superior  chain  of  glands,  leads  to  direct 
infection  of  the  cceliac  group  by  the  efferent  vessels  of  the 
inferior  chain  which  pass  behind  the  pylorus.  This  fact 
indicates  that  any  operation  devised  for  the  excision  of  a  pyloric 
growth  must  include  the  removal  not  only  of  the  superficial 
glands,  but  also  of  those  which  are  clustered  behind  the  organ 
and  around  the  cceliac  axis. 

The  inferior  gastric  glands  are  chiefly  involved  when  the 
neoplasm  affects  the  great  curvature.     Occasionally  their  en- 

F 


66  CANCEE  OF  THE   STOMACH 

largement  gives  rise  to  a  growth  between  the  stomach  and  the 
colon,  which  invades  the  bowel,  or,  by  exerting  pressure  upon 
a  nutrient  vessel,  induces  gangrene  of  its  walls  (Goullioud  and 
Mallard).  More  frequently  the  mischief  spreads  into  the 
lymphatics  of  the  great  omentum,  and  converts  that  tissue  into  a 
sausage-shaped  mass,  wThich  lies  transversely  across  the  epi- 
gastrium upon  the  anterior  surface  of  the  stomach. 

Extension  of  the  disease  to  the  general  peritoneum  is  accom- 
panied by  the  formation  of  numerous  discrete  nodules  upon  the 
surface  of  the  serous  membrane,  which  vary  from  the  size  of  a 
hempseed  to  that  of  a  walnut.  This  cancerous  peritonitis, 
besides  being  one  of  the  chief  causes  of  ascites  in  gastric  carci- 
noma, is  also  responsible  for  several  phenomena  of  clinical 
interest.  In  the  first  place,  it  is  liable,  like  other  varieties  of 
peritonitis,  to  produce  infection  of  the  lymphatics  of  the 
diaphragm,  or  to  be  followed  by  carcinosis  of  the  pleurae  and 
pericardium.  Secondly,  its  invasion  of  the  mesentery  and  the 
mesocolon  may  be  accompanied  by  so  much  contraction  of 
these  structures  that  the  intestines  are  drawn  backwards  to  the 
spine  and  their  presence  obscured  by  the  coexisting  ascites. 
Thirdly,  the  inflammation  occasionally  extends  into  the  sub- 
serous areolar  tissue,  which  becomes  greatly  indurated  and 
thickened,  and  not  only  gives  rise  to  compression  of  the  blood- 
vessels it  contains,  but  may  even  produce  obstruction  of  the 
ureters  (Bouveret).  Fourthly,  a  large  peritoneal  growth  in  the 
pelvis  often  contracts  adhesions  with  the  neighbouring  viscera, 
the  tissues  of  which  it  subsequently  invades  and  destroys.  In 
this  manner  the  ovaries,  uterus,  rectum,  bladder,  or  prostate  may 
become  the  seat  of  a  secondary  disease,  the  symptoms  of  which 
may  quite  overshadow  those  of  the  primary  growth.  Finally, 
disease  of  the  peritoneum  in  the  upper  part  of  the  abdomen  is 
not  infrequently  followed  by  an  invasion  of  the  abdominal 
parietes  or  by  secondary  deposits  in  the  skin.  In  the  former  case 
the  neoplasm  usually  spreads  to  the  linea  alba,  and  produces  a 
line  of  thickening  which  extends  from  the  ensiform  cartilage  to 
the  navel,  or  even  to  the  pubes.  In  the  latter  the  lymphatics  of 
the  round  or  of  the  falciform  ligament  convey  the  disease  to 
the  umbilicus,  which  becomes  retracted  and  fixed,  and  may 
subsequently  present  one  or  more  cutaneous  nodules.  This  con- 
dition is  sometimes  associated  with  multiple  growths  in  the 
subcutaneous  tissue  of  the  abdomen,  back,  or  thorax,  which  are 


THE   SEQUELS   OF  CAECINOMA  67 

usually  ascribed  to  infection  of  the  systemic  arteries.  As, 
however,  this  explanation  does  not  account  for  the  limitation  of 
the  disease  to  the  trunk,  we  prefer  to  attribute  it  to  a  direct 
extension  by  the  parietal  lymphatics  ;  and,  in  two  cases  where 
the  skin  of  the  thorax  exhibited  numerous  nodules,  we  were 
able  to  prove  after  death  that  the  mischief  had  spread  from  the 
anterior  mediastinum  into  the  intercostal  glands,  and  thence  into 
the  intercostal  lymphatic  vessels. 

The  coeliac  glands  constitute  an  important  intermediate 
centre  between  the  stomach  and  the  receptaculum  chyli.  They 
are  often  much  enlarged  in  growths  of  the  cardia  and  of  the 
posterior  wall,  and  sometimes  form  a  nodular  tumour,  which 
can  be  detected  during  life.  Softening  and  ulceration  of  their 
substance  may  lead  to  occlusion  of  the  inferior  vena  cava  or  to 
destruction  of  the  vertebral  column  (Brun).  In  nearly  every 
case  they  transmit  the  disease  to  their  pancreatic,  hepatic,  and 
splenic  tributaries. 

Invasion  of  the  receptaculum  chyli  marks  the  last  stage  in 
the  process  of  lymphatic  infection.  Through  the  medium  of 
this  reservoir  the  disease  may  be  propagated  backwards  to  the 
mesenteric,  lumbar,  and  sacral  glands,  and  thence  to  those 
situated  along  the  course  of  the  iliac  vessels  and  in  the  inguinal 
region.  Extension  of  the  mischief  in  an  upward  direction  takes 
place  through  the  thoracic  duct,  which  is  sometimes  found  to 
be  diseased  throughout  its  entire  length  or  occluded  by  masses 
of  cancer  cells  (Fenger). 

This  condition  is  usually  associated  with  extensive  infiltra- 
tion of  the  glands  in  the  posterior  mediastinum  and  of  those  at 
the  roots  of  the  lungs  and  at  the  bifurcation  of  the  trachea.  In 
about  3  per  cent,  of  all  cases  of  gastric  cancer  a  glandular 
enlargement  occurs  above  the  left  clavicle,  owing  to  the 
infection  of  the  cervical  tributaries  of  the  thoracic  duct,  while 
in  rare  cases  a  similar  condition  above  the  right  clavicle 
indicates  the  involvement  of  the  right  lymphatic  duct. 

C.    VASCULAE    INFECTION 

Carcinoma  of  the  stomach  is  apt  to  involve  the  vessels  in 
its  neighbourhood  either  by  direct  extension  or  through  the 
medium  of  the  lymphatics.  As  a  rule  the  veins  are  more 
affected  than  the  arteries,  and,  in  addition  to  a  general  infiltration 
of  their  walls,  they  not  infrequently  present  masses  of  epithelial 


68  CANCEE   OF  THE   STOMACH 

cells  which  project  into  their  lumina.  These  small  vegetations 
are  liable  to  be  swept  off  and  to  be  carried  by  the  blood  into 
other  viscera,  where  they  develop  into  tumours  of  the  same 
structure  as  the  original  growth.  In  other  cases  the  vein 
becomes  occluded  by  clot  and  the  thrombus  is  subsequently  in- 
filtrated by  cancer  cells. 

The  fact  that  the  veins  of  the  stomach  are  chiefly  directed 
into  the  portal  system  is  sufficient  to  explain  the  inordinate 
frequency  of  metastatic  deposits  in  the  liver.  These  vary 
greatly  both  in  number  and  size  ;  in  some  cases  only  one  or 
two  small  nodules  being  present,  while  in  others  the  whole 
organ  seems  to  be  converted  into  a  mass  of  cancer.  Secondary 
disease  of  the  liver  is  most  common  in  carcinoma  of  the  central 
and  cardiac  regions  of  the  stomach,  and  its  development  is  often 
excessive  when  compared  with  the  size  of  the  original  tumour. 
On  the  other  hand,  growths  of  the  pylorus  which  produce 
contraction  of  the  orifice  are  rarely  accompanied  by  metastases 
in  the  liver  (Table  7,  p.  56).  Occasionally  the  venous  infection 
is  limited  to  the  wall  of  the  stomach  and  is  accompanied  by 
thrombosis  of  the  coronary,  epiploic,  or  pyloric  veins ;  but  as  a 
rule  the  portal  trunk  itself  is  affected,  and  becomes  partially 
filled  with  masses  of  cancer  (Pressat,  Rendu),  or  even  com- 
pletely obstructed  by  them  (Labbe,  Contour). 

Carcinoma  may  infect  the  blood  of  the  systemic  veins  in 
three  ways  :  by  direct  invasion  of  the  inferior  vena  cava,  by 
the  extension  to  the  hepatic  veins  of  a  growth  of  the  liver,  or 
by  lymph  conveyed  through  the  thoracic  or  right  lymphatic 
ducts.  In  every  case  its  first  effect  is  to  produce  secondary 
deposits  in  the  lungs,  a  condition  which  is  met  with  in  nearly  8 
per  cent,  of  all  cancers  of  the  stomach.  These  metastases  usually 
develop  in  the  lower  lobes,  where  they  form  rounded  compact 
tumours  of  considerable  size  ;  but  occasionally  they  take  the 
form  of  a  miliary  growth  at  one  or  other  apex.  The  latter 
variety  may  closely  resemble  tubercle,  both  in  its  general 
appearance  and  also  in  its  tendency  to  undergo  softening  and 
caseation.  Brinton  seems  to  have  been  convinced  that  im- 
plication of  the  liver  greatly  diminished  the  risk  of  pulmonary 
infection  ;  but  this  view  has  not  been  supported  by  subsequent 
writers,  nor  does  the  fact  that  the  liver  was  affected  in  80  per 
cent,  of  our  cases  which  presented  pulmonary  growths  permit 
us  to  endorse  it.     Cancerous  infection  of  the  arterial  system 


THE   SEQUELAE  OF  CAECINOMA  69 

may  be  local  or  general.  The  former  is  chiefly  observed  in 
cases  where  the  gastric  growth  has  invaded  the  hepatic, 
coronary,  or  renal  arteries,  while  the  latter  is  nearly  always  the 
result  of  infection  of  the  systemic  veins.  The  fact  that  in 
cases  of  general  infection  the  lungs  are  not  always  the  seat  of 
secondary  growths  seems  to  indicate  that  cancer  cells  are 
capable  of  passing  through  the  pulmonary  capillaries  without 
producing  embolism.  After  gaining  an  entrance  to  the  left 
side  of  the  heart,  the  morbid  particles  are  immediately  directed 
into  the  systemic  arteries,  and  in  this  way  may  disseminate  the 
disease  throughout  the  body.  The  principal  organs  affected  in 
this  manner  are,  in  their  order  of  frequency — kidneys  (4  per 
cent.),  heart  (2-3  per  cent.),  ovaries  (2-3  per  cent.),  spleen  (2  per 
cent.),  bones  (2  per  cent.),  uterus  (I'D  per  cent.),  large  intestine 
(•7  per  cent.),  and  brain  (-7  per  cent.).  The  bones  usually 
affected  are  the  sternum,  humerus  (Marrotte),  and  sacrum 
(Bouveret) ;  while  disease  of  the  brain  is  interesting,  in  that  it 
is  almost  invariably  associated  with  a  tumour  of  the  lung. 

D.    TKANSPLANTATION 

This  is  chiefly  observed  in  the  case  of  the  peritoneum,  where 
the  implication  of  the  serous  coat  of  the  stomach  or  of 
the  great  omentum  is  sometimes  followed  by  the  develop- 
ment of  cancer  in  the  lower  abdomen.  In  such  cases  it  is 
probable  that  small  clumps  of  cancer  cells  become  detached, 
and,  being  aided  by  the  force  of  gravity,  fall  like  seed  into  one  of 
the  pelvic  pouches  and  subsequently  develop.  Transplantation 
upon  mucous  membranes  is  not  infrequently  observed  in  cases 
of  cancer  of  the  stomach  secondary  to  disease  of  the  oesophagus 
or  the  mouth  (p.  26). 

E.    CONTACT    INFECTION 

This  has  already  been  described  in  the  chapter  upon  Morbid 
Anatomy  (p.  23). 

8.  Jaundice 

This  was  present  in  13-7  per  cent,  of  our  cases  at  the 
time  of  death.  Its  frequency  varies  according  to  the  situa- 
tion of  the  growth  in  the  stomach.  Thus  it  occurred  in 
35  per  cent,  of  the  cases  where  the  disease  affected  the  lesser 
curvature  or  the  posterior  wall ;  in  20-5  per  cent,  of  the  pyloric 


70  CANCER   OF  THE   STOMACH 

infiltrations  unaccompanied  by  stenosis  or  dilatation  of  the 
stomach ;  in  7  per  cent,  of  the  growths  limited  to  the  cardia, 
and  only  in  5-6  per  cent,  of  those  which  had  produced  great 
contraction  of  the  pylorus.  With  regard  to  the  causation  of 
the  icterus,  it  was  noted  that  either  the  head  of  the  pancreas  was 
infiltrated  or  the  bile  duct  was  obstructed  in  four-fifths  of  the 
cases,  while  in  the  remainder  the  liver  was  the  seat  of  numerous 
secondary  deposits.  In  rare  instances  enlargement  of  the 
lymphatic  glands  in  the  portal  fissure  exerts  pressure  upon 
the  hepatic  duct  at  an  early  period  of  the  disease  (Michel). 

9.  Ascites 

An  excess  of  fluid  in  the  peritoneal  cavity  was  noted  in 
26  per  cent,  of  our  cases.  The  amount  varied  from  six 
ounces  to  several  quarts,  the  average  being  about  two  and  a 
half  pints.  As  a  rule  the  fluid  was  clear,  and  of  a  pale 
yellow  or  straw  colour,  but  occasionally  it  was  slightly  turbid 
or  presented  the  appearance  of  thin  pus.  In  two  cases  (075 
per  cent.)  chylous  ascites  was  observed.  When  associated 
with  jaundice  the  effusion  was  always  bile-stained,  but  in  two 
cases  this  feature  was  observed  although  the  skin  and  the 
conjunctivae  retained  their  natural  colour.  This  phenomenon 
seems  to  have  been  due  to  the  obstruction  of  the  thoracic 
duct,  which  was  present  in  both  instances,  and  which  probably 
prevented  the  entrance  of  the  bile  pigment  into  the  general 
circulation.  Blood  or  blood-stained  exudation  existed  in  rather 
less  than  one  quarter  (23  per  cent.)  of  the  cases  of  ascites,  and 
was  usually  attributable  to  the  presence  of  soft  hgeinorrhagic 
growths  upon  the  peritoneum,  but  in  two  instances  there  was 
coexistent  thrombosis  of  the  portal  vein. 

The  causation  of  ascites  in  gastric  cancer  is  a  matter  of 
some  importance.  We  find  that  in  50  per  cent,  of  our  cases  m 
which  it  occurred  the  peritoneum  was  the  seat  of  an  extensive 
carcinosis,  but  the  liver  was  free  from  disease  ;  in  21  per  cent, 
metastases  were  present  in  the  liver,  but  the  peritoneum  was 
healthy ;  while  in  the  remaining  29  per  cent,  both  structures 
were  affected  with  secondary  growths.  It  is  therefore  obvious 
that  the  extension  of  cancer  to  the  peritoneum  is  by  far  the 
most  important  factor  in  its  production. 

The  analysis  recorded  in  Table  8  indicates  that  ascites  only 


THE   SEQUELAE  OF  CAECINOMA 


71 


occurs  in  about  13  per  cent,  of  the  cases  where  the  pylorus 
is  contracted,  while  50  per  cent,  of  the  growths  of  the  carclia 
and  75  per  cent,  of  those  which  infiltrate  the  entire  viscus  are 
accompanied  by  peritoneal  effusion.  A  comparison  of  these 
figures  with  those  contained  in  Table  7  is  sufficient  to  explain 
this  curious  fact,  for  it  will  be  observed  that  neoplasms  of  the 
central  or  cardiac  region  of  the  stomach  are  not  only  more 
malignant  than  those  which  stenose  the  pylorus,  but  are  espe- 
cially prone  to  invade  the  peritoneum. 


Tablk  8. — Showing  the  Percentage  Frequency  of  Ascites  in  Carcinoma  of 
different  regions  of  the  stomach,  and  its  association  with  secondary 
Growths  of  the  Peritoneum  and  Liver 


Situation  of  the  gastric  disease 

Ascites 
present 

i 

Secondary  growths  in  cases  of 
ascites 

Perito- 
neum only 

Liver            -„  ,, 
only            Both 

Pylorus  (with  stenosis) 

Pylorus  (without  stenosis)    . 

Walls  and  curvatures   .... 

General  infiltration       .... 

13-2% 
20-6% 
34% 

53  8% 
75% 

67% 

14% 

50% 

55-5% 

50% 

33% 

14%           72% 
37-5%        12-5% 
11%          33-3% 
16-6%  '    33-3% 

10.  Thrombosis 

The  formation  of  a  clot  in  a  vessel  is  not  an  infrequent 
event  during  the  later  stages  of  cancer  of  the  stomach.  As 
a  rule  the  veins  are  more  often  affected  than  the  arteries, 
especially  those  of  the  lower  extremities.  Thrombosis  of 
the  common  iliac,  femoral,  or  saphenous  veins  was  observed 
in  4*5  per  cent,  of  our  cases.  The  condition  appears  to  be 
due  partly  to  the  general  debility  that  exists  towards  the 
end  of  life,  and  partly  to  the  feeble  action  of  the  heart  which 
ensues  from  the  wasting  and  degeneration  of  its  tissues.  It  is 
especially  frequent  in  cases  where  the  growth  occupies  the 
posterior  wall  of  the  stomach  and  is  accompanied  by  intense 
anaemia  (latent  cancer).  The  basilic  or  cephalic  veins  of  the  arm, 
or  the  internal  jugulars  (Bouveret),  are  occasionally  obstructed, 
while  in  rare  instances  most  of  the  superficial  veins  of  both 
the  upper  and  lower  extremities  may  be  affected  (Osier). 

Thrombosis  of  the  veins  wilhin  the  abdomen  or  thorax  is 
usually  due  to  their  direct  invasion  by  the  growth.     For  this 


72  CANCEE  OF  THE   STOMACH 

reason  the  portal  trunk  is  most  often  affected,  although  some- 
times its  splenic  or  mesenteric  tributaries  are  also  involved. 
Portal  thrombosis  was  noted  in  3  per  cent,  of  our  cases,  but  it 
is  probable  that  this  figure  underrates  the  frequency  with  which 
it  takes  place.  Suppurative  inflammation  of  the  vein  has  been 
observed  (Legg).  Less  frequently  the  inferior  vena  cava  is 
invaded  by  a  growth  of  the  posterior  surface  of  the  stomach, 
or  the  hepatic  veins  by  a  secondary  tumour  of  the  liver  ;  while  in 
one  of  our  cases  a  metastasis  in  the  superior  mediastinum  led 
to  thrombosis  of  the  right  innominate  vein  and  its  tributaries. 

Thrombosis  of  arteries  is  comparatively  rare,  and  is  usually 
preceded  by  atheroma,  unless  the  vessel  is  directly  involved  by 
the  neoplasm.  It  has  been  observed  to  take  place  in  the 
middle  cerebral  (Merklen,  Flint),  posterior  tibial,  and  left 
subclavian  (Langlet),  as  well  as  in  the  splenic,  hepatic,  colic, 
mesenteric,  and  renal  trunks.  In  one  case  we  found  simul- 
taneous occlusion  of  the  splenic,  right  renal,  and  right  posterior 
tibial  arteries.  Ante-mortem  clots  in  the  cavities  of  the  heart 
and  in  the  pulmonary  artery  are  usually  present  when  death 
has  been  preceded  by  coma. 


11.   Diseases  of  other  Organs 

A  careful  examination  of  the  various  tissues  of  the  body  after 
death  from  cancer  of  the  stomach  brings  to  light  two  important 
facts.  In  the  first  place,  it  would  appear  that  although  the 
disease  may  be  attended  by  many  and  diverse  complications,  it 
is  seldom  preceded  by  organic  changes  in  other  viscera  ;  in  other 
words,  carcinoma  is  particularly  prone  to  attack  those  who  have 
enjoyed  an  exceptional  immunity  from  disease.  Thus,  in  only 
17  per  cent,  of  our  cases  was  there  any  indication  of  antecedent 
mischief  in  an  important  organ  ;  whereas  in  chronic  ulcer,  which 
occurs  at  an  earlier  period  of  life,  some  old-standing  lesion  of 
the  lungs,  heart,  liver,  or  kidneys  is  found  in  at  least  40  per  cent. 
In  the  second  place,  in  those  cases  in  which  tuberculosis  and 
gastric  cancer  coexist  in  the  same  individual,  it  is  almost 
invariably  found  that  the  former  has  become  quiescent  or  even 
completely  obsolescent  before  the  onset  of  the  latter ;  indeed, 
in  the  whole  of  our  experience  we  are  unable  to  call  to  mind 
more  than  two  or  three  instances  where  active  tuberculosis  was 
present  along  with  a  cancerous  growth  in  the  stomach.     In  this 


THE   SEQUELS  OF   CAECINOMA  73 

connection  the  statements  of  Rokitansky  regarding  the  incom- 
patibility of  the  two  diseases  are  of  special  interest. 

(a)  The  Heart. — The  heart  participates  in  the  general  wast- 
ing, and  consequently  appears  after  death  to  be  remarkably 
small.  According  to  our  statistics  its  average  weight  in  the  male 
cases  was  8*2  oz.  and  in  the  female  7'5  oz. ;  and  since  the  normal 
average  in  the  two  sexes  is  11  oz.  and  9  oz.  respectively,  it  would 
seem  that  the  organ  usually  loses  about  one  quarter  of  its  initial 
weight  during  the  course  of  the  complaint.  The  smallest  heart 
(3^  oz.)  recorded  in  our  series  was  taken  from  a  young  man 
who  died  from  pyloric  stenosis,  and  Habershon  met  with  one 
of  similar  weight  in  a  woman  forty  years  of  age.  An  increase 
of  size  almost  always  indicates  the  existence  of  old  endocarditis. 
As  a  rule  the  walls  of  the  organ  are  flaccid,  and  its  cavities 
contain  decolorised  as  well  as  recent  clot.  The  muscular 
tissue  is  usually  flabby,  friable,  and  either  pale  or  dark  brown  in 
colour,  and  on  microscopical  examination  the  fibres  are  often 
found  to  be  remarkably  attenuated,  and  not  infrequently  to 
present  signs  of  fatty  degeneration.  An  excess  of  fluid  in  the 
pericardium  was  only  met  with  in  4  per  cent,  of  our  cases, 
and  acute  pericarditis  was  present  in  only  two  instances  (-7 
per  cent.),  in  both  of  which  it  was  secondary  to  suppurative 
pleurisy  on  the  left  side. 

Chronic  endocarditis  existed  in  4-6  per  cent.,  acute  ulcerative 
endocarditis  in  2-3per  cent.,  while  small  recent  vegetations  upon 
the  mitral  or  aortic  cusps  were  observed  in  nearly  4  per  cent. 
In  every  case  of  recent  endocarditis  the  growth  in  the  stomach 
was  extensively  ulcerated.  Secondary  deposits  in  the  heart  or 
its  serous  covering  occurred  in  23  per  cent.  Some  degree  of 
atheroma  of  the  aorta  was  present  in  31  per  cent.,  but  in  only 
7  per  cent,  was  it  extensive  ;  and  an  aneurysm  was  only  noted  in 
two  cases  ("7  per  cent.). 

(b)  The  Organs  of  Respiration. — An  excess  of  fluid  (hydro- 
thorax)  in  one  or  other  pleural  cavity  was  noted  in  3  per  cent,  and 
a  bilateral  effusion  in  6  per  cent,  of  our  cases.  Acute  pleurisy 
existed  in  14  per  cent.,  and  was  usually  accompanied  by  a 
moderate  amount  of  sero- fibrinous  exudation,  which  in  one 
seventh  of  the  cases  was  distinctly  blood-stained.  This  latter 
appearance  was  always  associated  either  with  metastatic  deposits 
in  the  pleura  or  with  a  similar  effusion  in  the  abdomen. 
Suppurative  pleurisy  was  never  encountered,  except  when  the 


74  CANCEE  OF  THE   STOMACH 

oesophagus  was  invaded  by  the  cancerous  disease.  Adhesions 
between  the  base  of  the  lung  and  the  diaphragm  existed  in 
16  per  cent.,  and  were  almost  twice  as  frequent  on  the  right  as 
on  the  left  side.  Secondary  growths  of  the  pleura  occurred  in 
about  4'5  per  cent,  of  all  cases ;  but  this  estimate  does  not 
include  those  in  which  the  lymphatics  were  visibly  distended 
with  cancer  juice  (Hillairet).  Obsolete  tubercle  was  found  in  16 
per  cent,  of  the  cases,  usually  near  the  apex  of  the  lung ;  but  a 
recent  extension  of  the  disease  was  never  observed.  Emphysema 
was  present  in  28  per  cent.  The  frequency  of  this  condition  has 
often  been  the  subject  of  comment,  and  it  is  usually  attributed 
to  antecedent  bronchitis.  Careful  inquiries,  however,  have  con- 
vinced us  that  the  subjects  of  gastric  cancer  rarely  suffer  from 
cough  or  shortness  of  breath  prior  to  the  onset  of  the  gastric 
complaint.  Moreover,  it  is  significant  that  this  variety  of 
emphj^sema  is  always  associated  with  atrophy  of  the  heart, 
whereas  in  ordinary  cases  the  right  ventricle  is  invariably  found 
to  be  enlarged.  It  is  also  noteworthy  that  the  degree  of 
emphysema  is  generally  proportionate  to  the  wasting  of  the  soft 
tissues,  and  is  most  marked  when  the  pyloric  orifice  of  the 
stomach  is  stenosed.  It  is  probable,  therefore,  that  this  form 
of  emphysema  is  due  to  atrophy  of  the  tissue  of  the  walls  of 
the  lung,  which  deprives  the  alveoli  of  their  natural  elasticity 
and  causes  them  to  become  dilated  under  the  pressure  of  their 
contained  air. 

Acute  pneumonia  was  noted  in  6  per  cent.,  and  was  usually 
lobular  in  its  distribution  and  affected  both  lungs  ;  but  occa- 
sionally it  occurred  in  the  form  of  a  grey  hepatisation  of  one  of 
the  lower  lobes.  Signs  of  bronchitis  and  of  oedema  existed  in 
every  case  where  death  was  preceded  by  coma,  while  secondary 
growths  were  present  in  7"6  per  cent,  of  our  cases. 

(c)  The  Spleen. — The  average  weight  of  the  spleen  in  our 
male  cases  was  5  oz.,  and  in  our  female  cases  4*2  oz.  Since 
its  normal  weight  varies  up  to  10  oz.,  it  is  obvious  that  the 
organ  is  considerably  reduced  in  size  in  malignant  disease  of 
the  stomach.  The  atrophy  is  most  marked  when  the  orifices  of 
the  stomach  are  the  seat  of  the  new  growth.  Thus,  its  average 
weight  was  3*8  oz.  when  the  cardiac  orifice  was  affected,  6-2  oz. 
in  disease  of  the  body  of  the  viscus,  and  4-6  oz.  when  the  pylorus 
was  implicated.  Infarction  occurred  in  about  2  per  cent,  of  the 
cases,  andin3"7  per  cent,  the  organ  was  the  seat  of  metastases. 


THE   SEQUELS  OF  CAECINOMA  75 

(d)  The  Liver. — As  the  liver  is  especially  liable  to  secondary 
growths,  it  was  necessary  to  select  only  those  cases  in  which  its 
structure  was  normal  in  appearance.  The  average  weight  of 
the  viscus  in  the  males  was  56  oz.,  and  in  the  females  42  oz.,  and 
since  its  normal  weight  in  the  male  varies  from  50  to  69  oz., 
it  is  evident  that  the  liver,  unlike  most  of  the  other  tissues 
of  the  body,  undergoes  little  diminution  in  bulk  during  the 
course  of  gastric  carcinoma.  This  anomaly  is  due  partly  to 
the  engorgement  of  the  portal  system  which  accompanies  a 
new  growth  in  the  stomach,  and  partly  to  the  fatty  infiltra- 
tion of  the  hepatic  structures  which  ensues  in  the  majority  of 
the  cases.  It  is  also  possible  that  the  constant  absorption  of 
deleterious  substances  resulting  from  disorganisation  of  the 
tumour  acts  as  a  stimulant  to  the  hepatic  cells.  In  support  of  this 
view  it  may  be  mentioned  that  the  average  weight  of  the  liver 
was  55  oz.  in  our  cases  of  pyloric  stenosis,  but  that  it  amounted 
to  61  oz.  when  the  body  of  the  stomach  was  the  seat  of  a  soft 
and  rapidly  growing  tumour.  It  is  interesting  to  notice  that 
only  in  one  instance  out  of  265  cases  (0*3  per  cent.)  was  the 
organ  affected  with  alcoholic  cirrhosis. 

(e)  The  Kidneys. — The  average  weight  of  these  organs  in 
our  male  cases  was  1T1  oz.,  and  in  the  female  9-5  oz. 
As  the  average  normal  weight  in  the  former  sex  is  10  oz. 
and  in  the  latter  8  oz.,  it  will  be  seen  that  the  kidneys 
usually  increase  in  bulk.  In  addition  to  the  signs  of  fatty 
degeneration  of  the  renal  epithelium,  which  are  frequently  met 
with,  chronic  interstitial  nephritis  was  observed  in  15-2  per 
cent,  and  chronic  parenchymatous  inflammation  in  8  per  cent, 
of  our  cases.  Both  varieties  were  exceptionally  common  in 
tumours  of  the  body  of  the  stomach,  and  apparently  developed 
during  the  course  of  the  gastric  complaint,  since  neither  albumi- 
nuria nor  oedema  was  ever  observed  before  the  commence- 
ment of  the  fatal  illness.  These  facts  appear  to  indicate  that, 
as  a  result  of  the  retrograde  changes  that  occur  in  the  morbid 
growth,  some  organic  substance  is  produced  which  is  absorbed 
into  the  system,  and  during  its  subsequent  elimination  acts 
as  an  irritant  to  the  renal  tissue.  Although  up  to  the  present 
time  we  have  not  succeeded  in  isolating  such  an  ingredient 
of  the  urine,  we  are  strongly  of  opinion  that  future  researches 
in  this  direction  will  not  only  prove  successful,  but  will  afford 
considerable  help  in  the  diagnosis  of  gastric  cancer.     Hydro- 


76  CANCER  OF  THE   STOMACH 

nephrosis  occasionally  results  from  the  pressure  upon  a  ureter  of 
a  peritoneal  or  subperitoneal  growth,  while  in  about 4  percent, 
of  all  cases  secondary  deposits  occur  in  one  or  both  kidneys. 

(/)  The  Alimentary  Canal.— (1)  The  (Esophagus. — Stricture 
of  the  cardiac  orifice  is  usually  attended  by  slight  dilatation  of 
the  lower  third  of  the  oesophagus  and  hypertrophy  of  its  muscu- 
lar coat.  Invasion  by  the  malignant  growth  occurs  in  about  46 
per  cent,  of  the  cases  of  primary  carcinoma  in  the  cardiac  half 
of  the  stomach,  and  not  infrequently  leads  to  perforation  of 
the  tube,  with  secondary  inflammation  of  the  left  pleura  or 
lung.  Towards  the  end  of  life  thrush  is  apt  to  extend  down- 
wards from  the  pharynx,  and  occasionally  enlargement  of  the 
solitary  glands  or  follicular  ulceration  is  observed  just  above 
the  cardiac  orifice. 

(2)  Stomach. — Chronic  gastritis  almost  invariably  accom- 
panies carcinoma  of  the  stomach.  At  an  early  stage  of  the  disease 
two  varieties  may  be  distinguished — the  parenchymatous  and 
the  interstitial  ;  but  at  a  later  period  they  usually  coexist. 

Chronic  Parenchymatous  Gastritis  is  most  common  in  cases 
of  soft  spheroidal-celled  and  cylinder-celled  growths  of  the  body 
of  the  organ.  To  the  naked  eye  the  mucous  membrane  appears 
soft,  swollen,  and  opaque,  or  exhibits  a  patch}7 form  of  congestion. 
On  microscopical  examination  the  superficial  epithelium  isfound 
to  be  partially  detached,  and  many  of  its  cells  are  seen  to  be 
distended  with  mucus.  The  ducts  of  the  glands  are  filled  with 
granular  and  fatty  cells  of  various  sizes  and  shapes,  with  a  few 
red  blood-corpuscles  and  a  considerable  quantity  of  debris. 
The  glands  themselves  are  usually  swollen,  irregular  in  outline, 
and  overlap  one  another.  No  lumen  is  visible,  and  no  distinc- 
tion can  be  made  between  central  and  parietal  cells.  At  some 
parts  of  the  section  the  tubules  are  completely  filled  with  poly- 
gonal cells  derived  from  the  peptic  cells  ;  at  others  their  contents 
consist  principally  of  fatty  detritus  ;  while  in  advanced  cases 
they  appear  shrivelled  and  empty  and  separated  from  one 
another  by  newly  formed  interstitial  connective  tissue.  The 
vessels  which  ramify  in  the  subtnucosa  are  dilated  and  engorged 
with  blood,  and  there  are  usually  signs  of  inflammatory 
exudation  around  the  smaller  arterioles  on  either  side  of  the 
musculari s  mucosal.  Occasionally  groups  or  lines  of  cancer 
cells  may  be  observed  in  the  lymph  spaces,  even  when  the 
section  has  been  made  at  some  distance  from  the  neoplasm. 


THE   SEQUELS  OF  CAECINOMA  77 

Chronic  Interstitial  Gastritis  invariably  accompanies  ob- 
struction of  the  pylorus  by  a  carcinomatous  growth.  In  such 
cases  the  inner  surface  of  the  stomach  exhibits  after  death  a 
thick  coating  of  tenacious  mucus,  and  when  this  has  been 
removed  the  mucous  membrane  presents  an  appearance  of 
extreme  congestion,  with  here  and  there  a  small  haemorrhage 
or  a  superficial  ulcer.  When  examined  by  the  microscope 
the  section  exhibits  an  irregular  or  distinctly  villous  sur- 
face, from  hypertrophy  of  the  connective  tissue  between 
the  mouths  of  the  ducts,  and  is  almost  denuded  of  epithe- 
lium. The  ducts  of  the  glands  are  twisted  and  distorted,  and 
their  lumina  are  often  choked  with  mucus,  detached  cells, 
and  debris.  The  glands  themselves  are  separated  from  one 
another  by  strands  of  fibrous  tissue,  the  thickness  of  which 
varies  in  different  places.  As  the  disease  progresses  the  peptic 
cells  of  the  cardiac  region  undergo  secondary  changes,  which 
ultimately  result  in  their  detachment  and  disintegration  ;  but  in 
the  pyloric  end  of  the  organ  the  comparatively  long  and  tortuous 
tubules  are  not  infrequently  constricted  by  the  new  interstitial 
tissue.  Under  these  circumstances  the  lower  ends  of  the  glands 
become  dilated  and  form  small  cysts,  which  are  lined  by  cubical 
epithelium  and  filled  with  mucus  (retention  cysts).  Extension 
of  the  inflammator}'  process  to  the  deeper  structures  destroys 
the  muscularis  mucosae  and  produces  partial  fibrosis  of  the 
submucosa. 

The  fact  that  both  varieties  of  inflammation,  as  well  as  a 
similar  lesion  of  the  intestine,  are  met  with  in  cases  of  scirrhus 
of  the  mamma  and  other  chronic  carcinomata,  renders  it  probable 
that  they  arise  from  the  absorption  of  some  deleterious  material 
produced  by  the  disintegration  of  the  neoplasm,  and  are  therefore 
allied  to  other  toxaemic  inflammations  of  the  digestive  tract. 

(3)  Small  Intestine. — Invasion  of  the  duodenum  by  continuity 
takes  place  in  about  5  per  cent,  of  the  cases,  but  metastases  are 
extremely  rare.  The  jejunum  is  occasionally  involved  and  its 
wall  destroyed  by  a  large  growth  of  the  pylorus. 

(4)  Large  Intestine. — This  portion  of  the  intestinal  tract  is 
very  liable  to  be  attacked  by  chronic  inflammation  during  the 
later  stages  of  gastric  carcinoma,  and  occasionally  membranous 
colitis  or  ulceration  is  discovered  after  death.  Metastases  are 
chiefly  met  with  in  the  rectum,  but  the  transverse  colon  is  often 
involved  by  a  growTth  of  the  pylorus  or  greater  curvature. 


78  CANCEE  OF  THE   STOMACH 


CHAPTEE   III 

ETIOLOGY 

1.  Frequency 

The  frequency  of  carcinoma  of  the  stomach  may  be  estimated 
either  from  data  supplied  by  a  large  series  of  necropsies,  from 
a  study  of  the  bills  of  mortality  of  different  countries,  or  from 
the  clinical  statistics  of  various  great  hospitals.  Each  of  these 
sources  of  information,  however,  presents  so  many  chances  of 
error  that  the  results  obtained  from  them  must  be  regarded  as 
strictly  relative  in  their  value.  Necropsies  are  obviously  the 
most  reliable,  in  so  far  as  the  actual  existence  of  the  disease  is 
concerned ;  but  since  only  a  certain  proportion  of  hospital 
patients  are  examined  after  death,  post-mortem  records  are  apt 
to  contain  an  excess  of  obscure  or  interesting  cases,  and  conse- 
quently to  exaggerate  the  frequency  of  all  varieties  of  abdominal 
disease.  Bills  of  mortality,  although  theoretically  perfect 
from  the  fact,  that  they  represent  all  causes  of  death  among 
all  classes  of  the  community,  are  based  almost  entirely  upon 
the  unverified  diagnoses  of  a  vast  number  of  medical  prac- 
titioners of  varying  knowledge  and  experience,  and  are  therefore 
always  open  to  grave  suspicion.1  Finally,  clinical  statistics  from 
the  hospitals  of  London,  while  they  undoubtedly  represent  an 
excellent  average  of  diagnosis,  are  concerned  entirely  with  the 
poorer  classes  of  an  urban  population,  and  consequently  lack 
the  most  essential  feature  of  the  statistics  of  mortality. 

1  In  this  connection  it  may  be  mentioned  that  out  of  fifty-six  cases  admitted 
under  our  care  into  hospitals  with  a  diagnosis  of  cancer  of  the  stomach,  thirty-one, 
or  553  per  cent.,  were  proved  to  be  suffering  from  that  complaint,  while  the  remain- 
ing 44  7  per  cent.,  were  free  from  the  disease.  The  average  duration  of  the  illness 
at  the  time  of  admission  was  nearly  four  months. 


ETIOLOGY 


79 


A.    POST-MOETEM    STATISTICS 

Out  of  8,468  necropsies  collected  principally  from  British 
hospitals,  Brinton  found  cancer  of  the  stomach  recorded  in  eighty- 
one,  or  in  about  1  percent. ;  while  14,974  performed  at  the  London 
and  London  Temperance  Hospitals  between  1880  and  1896  in- 
cluded 239  examples  of  the  disease  (l-6  per  cent.).  In  Paris, 
between  1861  and  1863  the  proportion  of  deaths  from  the  com- 
plaint in  every  hundred  deaths  was  1-9.  In  Berlin,  the  post- 
mortem statistics  of  Halm  and  Guttmann  present  a  ratio  of  2  9  ; 
in  Vienna  the  figure  would  appear  to  be  L5,  in  Prague  3*5,  in 
Helsingfors  4,  and  in  Copenhagen  9.  The  excessive  frequency 
of  the  disease  in  the  last-named  city  may  be  explained  to  some 
extent  by  the  advanced  age  of  most  of  the  patients  admitted  to 
the  hospitals,  but  it  is  interesting  to  remember  that  Copenhagen 
is  also  celebrated  for  the  prevalence  of  gastric  ulcer  (Dahlerup). 

Table  9. — Post-mortem  Statistics 


City 

Author 

ISTo.  of  necropsies 

No.  of  gastric 
cancers 

Percentage 

London 

Fenwick 

14,974 

239 

1-6 

Paris     . 

.      Salle     . 

22,503 

440 

1-9 

Berlin  . 

Hahn    and    Gntt- 

mann 

8,522 

247 

2-9 

Vienna . 

Gussenbauer    and 

Winiwarter 

61,287 

903 

1-47 

Prague . 

.      Welch  . 

11,175 

393 

3-5 

Helsingfors  . 

.      Holsti  . 

3,775 

152 

4-0 

Copenhagen . 

Griinfeld 

1,150 

102 

9-0 

B.    BILLS    OF    MOBTALITY 

Our  knowledge  derived  from  this  source  is  very  imperfect, 
since  most  of  the  registration  returns  refer  to  carcinoma 
generally  rather  than  to  its  relative  incidence  upon  different 
viscera.  The  material  at  hand,  however,  appears  to  point  to 
the  same  conclusion  as  that  deduced  from  the  study  of  post- 
mortem statistics,  namely,  that  the  complaint  varies  greatly  in 
frequency  in  different  parts  of  the  world.  Thus,  in  Paris  (1830- 
1840)  Tanchou  estimated  the  frequency  of  gastric  cancer  as 
compared  with  that  of  all  causes  of  death  at  0-6  per  cent. ;  in 
Vienna  it  is  stated  to  be  about  0'8  per  cent.,  in  Hamburg 
1-25  per  cent.,  in  Zurich  (1872-1874)  2  per  cent.,  in  Geneva 
(1855)  2-5  per  cent.,  in  Wiirzburg  (1852-1855)  1'9  per  cent., 
and  in  New  York  (1868-1882)  0-4  per  cent. 


80 


CANCER   OF  THE   STOMACH 


C.    CLINICAL    STATISTICS 

These  have  been  collected  froni  the  official  reports  of  six 
general  hospitals  in  London,  and  extend  over  a  period  of  ten 
years  or  more.  Their  chief  value  lies  in  the  fact  that  they 
probably  represent  the  best  average  of  diagnosis  that  it  is 
possible  to  obtain  ;  while  the  large  number  of  cases  dealt  with 
in  each  instance,  and  the  wide  area  from  which  they  were 
drawn,  help  to  reduce  the  margin  of  error  to  a  comparatively 
small  compass.  The  following  table  shows  the  results  obtained 
from  each  hospital,  and  also  affords  a  contrast  with  similar 
statistics,  derived  from  two  important  institutions  in  the  United 
States  and  one  in  Canada,  which  cover  the  same  period  of  time. 

Table  10 


Proportion  of 

deaths  from  gas- 

,,,.   , 

Gastric 

Per- 

tric cancerper  100 

Hospital 

Period 

admissions 

cancers 
(diagnosed) 

centage 

medical  deaths 

At  all     Over  20 

ages        years    | 

The  London 

.     1890-1899 

47,169 

236 

0-5 

1-4 

\ 

St.  Bartholomew's 

.    1887-1899 

30,868 

146 

0-47 

1-7 

) 

St.  Thomas's 

.     1887-1899 

24,600 

139 

0-56 

1-4 

\  3'1 

Westminster 

.     1884-1900 

18,175 

92 

0-5 

1-2 

London  Temperance 

.     1890-1899 

4,643 

20 

0-43 

1-5 

J 

University  Coilege 

.  J1882-1890 

11,006 

69 

0-62 

1-3 

— 

Johns  Hopkins   . 

.     1889-1898 

8,464 

150 

1-7 

— 

— 

Massachusetts    . 

.     1889-1897 

11,812 

129 

1-0 

— 

— 

,  Montreal     . 

.     1889-1897 

9,458 

54 

0-57 

— 

A  careful  examination  of  these  figures  brings  to  light  several 
interesting  and  important  facts.  In  the  first  place,  it  will  be 
observed  that,  in  spite  of  the  varying  numbers  of  patients  who 
were  admitted  into  the  different  hospitals  of  London,  the  per- 
centage frequency  of  carcinoma  of  the  stomach  as  diagnosed  in 
the  wards  is  practically  the  same  in  every  instance,  and  re- 
presents about  0-5  per  cent,  of  all  the  medical  admissions. 
Secondly,  the  proportional  death-rate  from  the  disease  is  also 
almost  identical  in  each  institution,  namely,  1*4  per  cent,  of  all 
the  medical  deaths.  Thirdly,  if  the  fatal  cases  in  the  medical 
wards  are  analysed  according  to  age,  it  is  found  that  for  every 
100  persons  who  died  after  the  age  of  twenty  years,  3-l 
succumbed    to    carcinoma    of    the    stomach.      Finally,  it    is 


ETIOLOGY  81 

worthy  of  notice  that  the  complaint  was  responsible  for  13*1 
per  cent,  of  all  the  deaths  which  resulted  from  diseases  of  the 
digestive  organs.1 

The  Relative  Liability  of  different  Organs. — Much  discus- 
sion has  taken  place  regarding  the  liability  of  the  stomach  to 
carcinoma  as  compared  with  that  of  the  other  organs  of  the  body. 
Brinton  considered  that  the  gastric  lesion  constituted  about 
33  per  cent,  of  all  primary  cancers ;  Virchow  estimated  it  at 
34-9  per  cent. ;  d'Espine  at  44-37  per  cent. ;  Tanchou  at  25-2 
per  cent.;  Salle  at  31-9  per  cent.;  Welch  at  25-7  per  cent.; 
Haberlin  at  41-5  per  cent. ;  Holsti  at  53-9  per  cent. ;  Eisenhart 
at  18-92  per  cent. ;  Beiche  at  35*5  per  cent.  ;  and  Biegel  at  50 
per  cent.  Out  of  3,011  -  primary  carcinomata  the  diagnoses  of 
which  were  verified  after  death,  the  stomach  was  the  seat  of  the 
growth  in  1,006,  or  in  33-4  per  cent.,  and  the  uterus  in  984,  or 
in  32-6  per  cent.  ;  while  among  43,894  unverified  cases  included 
in  various  bills  of  mortality,  10,442,  or  23-7  per  cent.,  presented 
disease  of  the  stomach,  and  8,900,  or  20-2  per  cent.,  of  the  uterus. 
It  is  worthy  of  notice  that  the  relative  liability  of  the  two 
organs  seems  to  vary  considerably  in  different  places.  Thus,  in 
England  the  ratio  of  gastric  to  uterine  carcinoma  is  about 
7:6;  in  Hamburg,  nearly  2:1;  in  Berlin,  7:5;  in  Prague, 
7  :  6 ;  in  Wiirzburg,  7  :  4 ;  in,  Helsingfors,  7  :  1,  and  in  Geneva, 
3  :  1.  In  New  York  and  Paris  and  in  Australia  the  two  organs 
are  said  to  be  equally  affected,  while  in  Vienna  the  uterus 
is  apparently  more  frequently  diseased  than  the  stomach. 
Two  conclusions  may  be  drawn  from  these  facts  :  (1)  That  at 
least  50  per  cent,  of  all  primary  carcinomata  develop  either  in 
the  stomach  or  in  the  uterus  ;  (2)  that  while  the  uterus  is 
relatively  more  often  affected,  since  it  is  a  viscus  of  one  sex 
only,  the  stomach  is  absolutely  the  most  frequent  seat  of  the 
disease,  and  its  lesion  constitutes  30-35  per  cent.,  or  about  one- 
third,  of  all  primary  carcinomata. 

The  Increase  of  the  Disease. — That  the  death-rate  from 
carcinoma  generally  is  steadily  increasing  in  almost  every  part 
of  the  civilised  world  hardly  admits  of  doubt.     In  the  report  of 

1  These  include  the  various  diseases  of  the  oesophagus,  stomach,  intestines, 
liver,  pancreas,  and  peritoneum  which  were  treated  in  the  medical  wards.  The 
figures  were  too  complex  to  insert  in  the  table. 

2  The  post-mortem  material  was  derived  from  the  records  of  hospitals  in 
London,  Paris,  Berlin,  and  Prague,  and  the  mortuary  statistics  from  England 
(1899),  Paris,  New  York,  Geneva,  Wiirzburg,  and  Frankfort-on-Main. 

Q 


82 


CANCEE  OF  THE   STOMACH 


the  Kegistrar-General  for  England  for  1896,  the  statistics  bear- 
ing npon  this  question  are  arranged  in  groups  of  five  years, 
from  1861  to  1895  inclusive,  and  show  the  following  death- 
rate  from  cancer  per  100,000  living. 


Table  11 


Date. 

1861-1865 

1866-1870 

1871-1875 

1876-1880 

1881-1885 

1886-1890 

Death-rate 

36-78 

40-38 

44-56 

49-36 

54-76 

63-16 

Date  .... 

1891-1895 

1896 

1897 

1898 

1899 

1900  • 

Death-rate 

71-22 

76-4 

78-3 

79-8 

82-5 

82-8 

In  1896  the  death-rate  per  100,000  living  was  76-4,  in  1897 
78-3,  in  1898  79-8,  and  in  1900  82-8.  In  other  words,  during 
the  last  thirty  years  the  death-rate  from  this  cause  has  been 
nearly  doubled.  J.  D.  Bryant,  of  New  York,  has  shown 
that  the  disease  is  constantly  on  the  increase  in  the  United 
States,  and  that  the  mortality  from  it  has  been  trebled  between 
1860  and  1890. 

According  to  Kirchner,  the  death-rate  from  cancer  in  Prussia 
per  10,000  living  had  risen  from  3*73  to  5-29  in  the  case  of 
men,  and  from  4*45  to  6-03  in  the  case  of  women,  during  the 
period  1888  to  1897.  Hirschberg's  statistics  for  Berlin  show 
an  increase  in  the  mortality  from  the  disease  per  million  living 
from  657  men  and  1,126  women  in  1876  to  1,537  men  and  1,775 
women  in  1895. 

In  Australia,  Mullins  found  that  the  death-rate  from  cancer 
had  been  trebled  between  1857  and  1893  ;  while  in  New  Zea- 
land, Macdonald  states  that  it  was  twice  as  great  in  1889 
as  in  1879. 

The  fact  that  until  quite  recently  it  was  the  custom  in  official 
returns  to  consider  malignant  disease  in  its  entirety  rather  than 
as  regards  the  organ  that  was  primarily  affected,  renders  it 
difficult  to  offer  much  statistical  evidence  as  to  the  increase  or 
otherwise  of  the  gastric  lesion.  Haberlin  was  the  first  to  point 
out  that  in  Switzerland  the  frequency  of  gastric  carcinoma  is 
constantly  increasing,  and  compiled  the  following  table,  which 


The  rates  1897-1900  have  been  corrected  by  the  new  census  returns. 


ETIOLOGY 


shows  the  death-rate  from  the  disease  per  1,000  inhabitants  of 
that  country  from  1877  to  1886. 


T. 

LBLE    12 

Date 

1S77 

1878 

1879 

1880 

1881 

1882 

1883 

1884 

1885 

1886 
0-99 

Death- 
rate  . 

0-61 

0-66 

0-72 

0-77 

0-85 

0-87 

0-85 

0-84 

090 

In  the  report  of  the  Begistrar-General  for  England  for  1889 
figures  are  given  for  certain  areas  in  1868  and  1888  respectively. 
The  death-rate  per  million  living  of  thirty-five  years  and  up- 
wards from  cancer  of  the  stomach  was,  in  1868,  males  283*65, 
females  193-45.  In  1888  it  had  risen  to  346-15  in  men  and 
277*75  in  women.  In  other  words,  there  was  an  increase  of  22 
per  cent,  in  males  and  44  per  cent,  in  females. 

According  to  the  census  returns  of  the  United  States  for 
1880,  in  certain  groups,  among  1,000  deaths  from  cancer  where 
the  seat  of  the  disease  was  known  there  were  300-18  from 
cancer  of  the  stomach.  The  total  deaths  from  this  cause  were 
2,133,  which,  in  a  population  for  the  area  of  about  29,000,000, 
gives  one  death  from  the  disease  in  every  13,595  living.  In 
1890  certain  areas  gave  a  rate  of  one  death  to  every  9,761  living 
(Osier  and  McCrae). 

Both  in  Hamburg  and  Helsingfors,  and  more  especially  in 
the  latter  town,  the  death-rate  from  the  disease  has  greatly 
increased  during  the  last  twenty  years  (Eeiche,  Holsti). 

From  the  following  figures,  supplied  to  us  by  Dr.  Tatham,  it 
will  be  seen  that  the  death-rate  from  the  disease  in  England 
has  only  slightly  increased  in  both  sexes  during  the  last  few 
years. 

Table  13. — Mortality  prom  Carcinoma  op  the  Stomach  per  Million 
LrviNG  (England  and  Wales) 


Tear 

Males 

Females 

1897 
1898 
1899 
1900 

130 
139 
137 
138 

123 
123 
128 
135 

We  have  also  collected  statistics  from  three  of  the  largest 
hospitals  of  London  for  two  periods  of  five  years  each,  the  first 


84 


CANCEE   OE  THE   STOMACH 


being  1881  to  1885,  and  the  second  1895  to  1899.  The  results, 
which  are  expressed  in  the  following  table,  show  that  the  per- 
centage frequency  of  gastric  carcinoma  in  the  medical  wards 
increased  from  04  to  0-6,  and  the  proportional  death-rate 
from  the  disease  from  1*42  to  1*82  per  cent,  in  the  course  of 
fifteen  years.  It  must  be  borne  in  mind,  however,  that  the 
rapid  advance  that  has  taken  place  in  abdominal  surgery  since 
1885  has  caused  many  cases  to  be  transferred  from  the  medical 
to  the  surgical  wards,  and  at  the  same  time  has  probably 
induced  a  larger  number  to  seek  hospital  treatment ;  and  since 
it  is  impossible  to  calculate  the  relative  influence  of  these  two 
factors,  no  absolute  conclusion  can  be  drawn  from  the  figures. 

Table  14 


Period 

Total  medical 
admissions 

Gastric  cancers 
(diagnosed) 

Percentage 

Proportional  death- 
rate  per  100  medical 
deaths 

1881-1885 
1895-1899 

39,011 
46,025 

159 
279 

0-4 
0-6 

1-42 
1-82 

Newsholme  and  King  consider  that  the  increase  of  cancer 
is  more  apparent  than  real,  and  may  be  explained  by  the  better 
methods  of  diagnosis  that  are  now  in  vogue.  For  our  own 
part,  however,  we  believe  that  every  advance  which  is  made  in 
practical  medicine  is  more  likely  to  diminish  than  to  increase 
the  apparent  death-rate  from  carcinoma  of  the  stomach.  Thus, 
a  medical  man  whose  knowledge  is  deficient  usually  regards  a 
fatal  complaint  accompanied  by  indigestion,  vomiting,  and  loss 
of  flesh,  as  cancer  of  the  stomach ;  whereas  another,  who  is 
better  versed  in  the  science  of  diagnosis,  will  often  discover  that 
the  symptoms  are  due  to  simple  ulcer,  kidney  disease,  stricture 
of  the  bowel,  phthisis,  or  to  a  tumour  of  the  brain.1  Again,  it 
was  formerly  the  custom  to  regard  carcinoma  as  the  principal 
cause  of  pyloric  stenosis,  and  in  the  absence  of  a  necropsy 
almost  every  case  which  presented  signs  of  dilatation  of  the 
stomach  was  recorded  as  '  cancer.'  At  the  present  time,  how- 
ever, it  is  universally  recognised  that  the  cicatricial  contraction 
of  a  simple  ulcer  or  adhesions  to  the  gall-bladder  are  respon- 
sible for  a  large  proportion  of  all  strictures  of  the  pylorus, 
and  that  the  modern  methods  of  diagnosis  permit  them  to  be 
distinguished  from  the  malignant  variety  during  life.  Finally, 
1  See  footnote,  p.  78. 


ETIOLOGY  85 

the  more  ignorant  the  practitioner,  the  greater  is  the  probability 
that  he  will  regard  all  palpable  tumours  of  the  abdomen  as 
'cancerous ; '  while  the  better  his  education,  the  more  readily  will 
he  differentiate  between  visceral  enlargements  and  true  tumours, 
and  between  the  malignant  and  benign  varieties  of  the  latter. 
For  these  several  reasons  we  are  strongly  of  opinion  that  with 
the  growth  of  medical  education  the  apparent  mortality  from 
abdominal  carcinoma  will  exhibit  a  slower  rate  of  increase  than 
is  observed  in  the  case  of  the  so-called  '  accessible  organs.' 

2.  Sex 

It  was  formerly  the  custom  to  regard  the  disease  as 
especially  common  in  men,  and  the  statement  of  Brinton,  that 
it  is  twice  as  frequent  in  males  as  in  females,  was  for  a  long 
time  regarded  as  indisputable.  More  extensive  observations, 
however,  have  shown  that  the  data  which  formed  the  basis  of 
that  author's  researches  were  insufficient  to  warrant  many  of 
the  conclusions  which  he  drew  from  them.  Thus,  Fox  found 
that  in  his  series  of  1,303  cases  the  sexes  were  almost  equally 
represented  (680  :  623),  while  in  the  2,214  analysed  by  Welch, 
nearly  all  of  which  had  been  verified  by  necropsy,  there  were 
1,233  males  and  981  females,  a  ratio  of  5  to  4.  With  the  aid  of 
recent  statistics  we  find  that  out  of  a  total  of  3,679  post-mortem 
examinations  of  gastric  cancer,  2,162  were  males  and  1,517 
females,  which  gives  a  proportion  of  rather  less  than  6  to  4.1 

Clinical  records  afford  somewhat  similar  results,  for  out  of 
130,000  persons  admitted  into  the  medical  wards  of  hospitals 
in  London,  we  find  that  -6  per  cent,  of  the  males  and  -4  per  cent, 
of  the  females  were  considered  to  be  suffering  from  malignant 
disease  of  the  stomach.  Both  these  sets  of  figures,  however, 
probably  exaggerate  the  frequency  of  the  complaint  in  men, 
since  all  post-mortem  statistics  present  an  excess  of  males, 
while  the  medical  admissions  of  women  into  hospitals  include 
not  only  a  considerable  number  of  obstetric  cases,  but  also 
an  undue  proportion  of  minor  ailments. 

The  bills  of  mortality  of  certain  great  cities  seem  to  indicate 
that  very  little  difference  exists  in  the  liability  of  the  two  sexes. 

1  These  figures  include  those  of  Dittrich,  Wrany,  Eppinger,  Brinton,  Virchow, 
Lebert,  Leudet,  Katzenellenbogen,  Lange,  Habershon,  Gussenbauer  and  v.  Wini- 
warter, Hahn,  Salle,  Guttmann,  Holsti,  Martin,  Perry  and  Shaw,  and  those 
derived  from  the  London,  the  London  Temperance,  and  the  Munich  Hospitals. 


86  CANCEE  OF  THE   STOMACH 

Dr.  Tatham  informs  us  that  in  England  and  "Wales,  during 
the  four  years  1897-1900,  the  deaths  from  malignant  disease  of 
the  stomach  comprised  8,369  males  and  8,355  females.  Ledoux- 
Lebard  states  that  in  Vienna  the  incidence  of  the  complaint  is 
practically  equal  in  the  two  sexes.  Welch  came  to  a  similar 
conclusion  after  an  exhaustive  study  of  the  records  of  the  Board 
of  Health  for  New  York ;  while  in  Hamburg,  Beiche  found  that 
out  of  every  hundred  deaths  in  each  sex,  1*3  of  the  males  and 
1*1  of  the  females  died  from  cancer  of  the  stomach.  It  may 
therefore  be  concluded  that  although  men  may  be  slightly 
more  often  affected  by  the  disease  than  women,  the  difference 
is  too  insignificant  to  merit  special  consideration. 

With  regard  to  the  influence  of  sex  upon  the  situation  of 
the  growth  there  is  very  little  to  be  said ;  but  from  our  own 
cases  it  would  appear  that  stenosis  of  the  pylorus  is  rather  more 
common  in  women  than  in  men,  while  the  reverse  is  the  case 
as  regards  disease  of  the  body  of  the  stomach. 

3.  Age 

Carcinoma  of  the  stomach  may  be  said  to  be  a  disease  of 
maturity.  Scheffer  found  that  only  2  per  cent,  of  the  cases 
which  he  collected  were  less  than  thirty  years  of  age; 
Brautigam's  estimate,  made  on  similar  lines,  was  2-5  per  cent., 
Beichert's  3  per  cent.,  while  our  results  indicate  a  ratio  of  2*5 
per  cent.  In  the  following  table  we  have  arranged  2,604  fatal 
cases  (necropsies)  according  to  the  age  of  each  individual  at  the 
time  of  death,  and  in  the  next  one  882  cases  which  were  dia- 
gnosed at  various  hospitals  in  London. 

Table  15. — An  Analysis  of  2,604  Necropsies  upon  Gastric  Carcinoma, 

SHOWING    THE    AGE    AT    THE    TlilE    OF    DEATH 


No.  of  cases 

Percentage 

4 

•15 

64 

2-4 

357 

137 

660 

25-3    ) 

777 

29-8    ^=77-0 
21-9   j 

570 

149 

5-7 

20 

076 

3 

011 

2,604 

100 

Under  ten 
Ten  to  twenty 
Twenty  to  thirty 
Thirty  to  forty 
Forty  to  fifty    . 
Fifty  to  sixty  . 
Sixty  to  seventy 
Seventy  to  eighty 
Eighty  to  ninety 
Over  ninety 


Total 


ETIOLOGY 


87 


Table  16. — Ax  Analysis  of  8S2  Clinical  Cases,  showing  the  Age  at 
the  Time  of  Death 


Age 

No.  of  cases 

Percentage 

Under  ten 
Ten  to  twenty 
Twenty  to  thirty 
Thirty  to  forty 
Forty  to  fifty  . 
Fifty  to  sixty  . 
Sixty  to  seventy 
Seventy  to  eighty 
Eighty  to  ninety 
Over  ninety     . 

3 

29 
126 
262 
291 
158 

13 

0-34 
3-3 
14-3 

29-7   ) 
33       U06 
17-9   ) 
1-47 

Total         .         .         .         .         . 

882 

100 

It  will  be  observed  that  in  the  main  the  results  expressed 
in  the  two  tables  are  in  accord  with  one  another.  In  both  the 
greatest  number  of  cases  in  any  decade  occurs  between  fifty  and 
sixty ;  while  the  aggregate  between  forty  and  seventy  amounts 
in  each  instance  to  about  80  per  cent,  of  the  whole.  On  the 
other  hand,  the  series  of  necropsies  which  were  collected  from 
different  cities  of  Europe  present  a  greater  proportion  of  cases 
over  seventy  years  of  age  than  do  the  clinical  figures  from 
London.  This  is  readily  explained  by  the  fact  that  in  London 
the  aged  poor  who  are  afflicted  with  incurable  diseases  are 
more  often  admitted  to  workhouse  infirmaries  than  into  general 
hospitals,  while  in  other  countries  this  distinction  is  not 
observed. 

These  two  sets  of  figures,  although  of  interest  in  their  own 
way,  merely  indicate  the  period  of  life  at  which  the  majority  of 
the  cases  of  gastric  carcinoma  come  under  medical  observation, 
and  obviously  afford  no  evidence  as  to  the  relative  liability  of 
the  population  to  the  complaint  at  different  periods  of  life. 
We  have  therefore  appended  the  following  tables,  which  have 
been  compiled  for  us  by  Dr.  Tatham. 

In  the  first  table,  which  refers  solely  to  cases  met  with  in 
hospital  practice,  the  maximum  liability  to  the  complaint 
appears  to  occur  between  fifty-five  and  sixty-five  years  of  age, 
and  thus  corroborates  the  evidence  obtained  from  the  post- 
mortem and  clinical  statistics  previously  quoted.  When,  how- 
ever, the  deaths  from  carcinoma  of  the  stomach  occurring  in  the 
whole  county  of  London  are  taken  into  consideration,  it  at  once 
becomes  evident  that  the  disease  increases  in  frequency  up  to 


88 


CANCEE  OE  THE   STOMACH 


Table  17. — Death-bate  feoii  Canceb  of  the  Stomach  (Fatal  Cases  in 
London  Hospitals) 


Ages   . 

"Under  25 

25-35 

35-45 

45-55 

55-65 

65-75 

75  and 

upwards 

Population  . 

2,281,861 

810,688 

592,166 

414,296 

260,173 

133,022 

52,777 

Cases  . 

3 

19 

73 

82 

61 

22 

1 

Rate    (per 

million) 

1 

23 

123 

198 

234 

165 

19 

Percentage 

to  No.  at 

all  ages    . 

1-1 

7-3 

28-0 

31-4 

23-4 

8-4 

04 

Table  18. — Death-bate  fbom  Canceb  of  the  Stomach  (Registeation 
Retuens  foe  London,  1901) 


Ages     .           ... 

Under  25 

25-35 

35-45          45-55 

55  65 

65-75       Over  75 

Population       (Male 

| 

and  Female) . 

2,281,861  810,688 

592,166  414,296 

260,173 

133,022  52,777 

Deaths     (Cancer  of 

Stomach) 

1 

13 

60 

131 

164 

137 

47 

Rate     (per    mil- 

lion) 

— 

16 

101 

316 

630 

1,030 

891 

Percentage  of  deaths 

at  specified  ages  to 

deaths  at  all  ages  . 

0-2 

2-4 

10-8        23-7 

29-6 

24-8 

8-5 

seventy-five  years  of  age,  and  that  the  niaxiinuni  liability 
really  occurs  between  sixty-five  and  seventy-five.  The  fallacies 
inherent  in  hospital  statistics  regarding  the  influence  of  sex 
in  disease  have  already  been  noted,  and  it  now  becomes  evident 
that,  owing  to  the  infrequent  admission  of  old  persons  into 
general  hospitals,  the  effect  of  age  has  also  been  misjudged. 
We  therefore  conclude  that,  contrary  to  the  usual  teaching,  the 
tendency  to  gastric  carcinoma  steadily  increases  with  each 
decade  of  life  until  about  the  age  of  seventy-five. 

It  was  formerly  believed  that  carcinoma  never  attacked  the 
stomach  before  puberty,  but  there  is  now  sufficient  evidence  to 
prove  that  the  disease  does  occasionally  develop  during  child- 
hood. Six  cases  have  been  reported  in  children  less  than  ten 
years  of  age,  but  in  most  of  them  the  details  given  of  the 
necropsy  are  hardly  conclusive  as  to  the  existence  of  primary 
cancer  of  the  stomach.  Thus,  the  one  recorded  by  Williamson 
in  1841  was  almost  certainly  an  example  of  hypertrophic 
stenosis  of  the  pylorus ;  while  in  those  related  by  Kaulich  and 


ETIOLOGY  89 

Widerhofer  both  the  nature  of  the  growth  and  its  primary  loca- 
tion are  very  doubtful.  Kuhn's  case  would  appear  to  have  been 
an  example  of  lymphosarcoma. 

In  1877  Cullingworth  published  the  case  of  an  infant  who 
commenced  to  vomit  on  the  tenth  day  after  birth,  and  died  of 
exhaustion  in  the  sixth  week.  The  necropsy  showed  a  soft 
pedunculated  tumour,  which  had  almost  occluded  the  pyloric 
orifice  and  given  rise  to  great  dilatation  of  the  stomach.  On 
microscopical  examination  the  growth  was  found  to  possess  the 
structure  of  a  cylinder-celled  carcinoma,  and  as  an  example  of 
such  it  has  always  been  quoted,  although  it  seems  to  us  that 
the  possibility  of  a  congenital  adenoma  has  never  been  duly 
considered.  Ashby  and  Wright's  case  was  a  child  eight  years 
of  age  who  presented  an  abdominal  tumour  during  life.  After 
death  considerable  dilatation  of  the  stomach  was  found,  along 
with  an  ulcerated  cylinder-celled  carcinomatous  ulcer  of  the 
duodenum  and  two  growths  the  size  of  peas  on  the  cardiac  side 
of  the  pylorus. 

Between  ten  and  twenty  years  of  age  the  complaint  is  less 
infrequent,  although,  of  the  sixteen  cases  which  are  said  to  have 
occurred  at  this  period,  at  least  four  appear  to  have  been 
examples  of  lymphosarcoma.  In  this  category  we  would 
include  the  case  of  a  boy  who  came  under  our  notice  for  pain 
in  the  abdomen,  vomiting,  and  emaciation.  The  epigastrium 
and  umbilical  region  were  occupied  by  a  hard  tender  swelling, 
which  moved  slightly  with  respiration  and  rapidly  increased  in 
size.  After  death,  which  occurred  in  three  months,  the  stomach 
and  duodenum  were  found  to  be  infiltrated  with  a  soft  growth, 
which  had  produced  metastases  in  the  mesenteric  glands  and 
peritoneum.  Although  the  disease  was  supposed  to  be  en- 
cephaloid  cancer,  microscopical  examination  left  little  doubt 
that  it  was  really  lymphosarcoma. 

After  the  age  of  twenty  the  disease  increases  in  frequency, 
and 'the  cases  that  occur  during  the  third  decade  comprise  2*4 
per  cent,  of  those  at  all  ages. 

Sex  appears  to  exert  little  influence  upon  the  period  of  life 
at  which  the  disease  commences,  since  between  thirty-five  and 
seventy-five  years  of  age  its  proportional  incidence  in  males 
and  females  is  practically  identical  in  each  decade.  It  is  inter- 
esting to  notice,  however,  that  the  precocious  development  of 
gastric  cancer  is  far  more  common  in  males  than  in  females,  for 


90  CANCEE  OF  THE   STOMACH 

out  of  twenty-five  cases  occurring  before  the  age  of  thirty  which 
we  have  collected  from  different  sources,  no  fewer  than  twenty- 
one  were  of  the  former  sex,  a  ratio  of  more  than  5  to  1.  As  far 
as  our  researches  go,  spheroidal-celled  carcinoma  appears  to  be 
more  frequent  in  the  young  than  the  cylinder-celled  variety, 
and  colloid  changes  are  relatively  more  common. 


4.  Geographical  Distribution 

The  chief  difficulty  of  determining  the  relative  frequency 
of  carcinoma  in  different  parts  of  the  globe  is  due  to  the 
extraordinary  deficiency  of  trustworthy  observations.  In  many 
instances  our  sole  information  upon  the  subject  is  derived 
from  the  general  impressions  of  some  explorer  more  or  less 
versed  in  medical  matters,  while  in  not  a  few  cases  dogmatic 
inferences  have  been  drawn  from  the  experiences  of  a  single 
individual  extending  over  a  very  limited  period.  Thus  it  is 
the  custom  to  state  that  cancer  of  the  stomach  is  very  rare 
in  Vera  Cruz,  because  Heinemann  happened  to  see  only 
one  example  of  the  complaint  during  a  residence  of  six  years 
in  that  city ;  while  its  supposititious  infrequency  in  Japan 
has  been  founded  upon  the  equally  limited  experience  of 
Schulze.  "When  one  considers  how  many  medical  men  in  the 
rural  districts  of  England,  and  even  in  London,  must  fail  to 
meet  with  a  case  of  gastric  cancer  during  the  first  six  years 
of  practice,  it  appears  almost  incredible  that  such  worth- 
less statements  should  ever  have  been  regarded  as  worthy  of 
notice. 

As  far  as  our  present  knowledge  extends,  carcinoma  may  be 
said  to  exist  among  all  the  civilised  nations  of  the  globe.  In 
Great  Britain,  France,  Spain,  Germany,  Austria,  Italy,  Bussia, 
and  Norway,  it  is  not  only  rife  but  increasing  in  frequency.  In 
Denmark  it  appears  to  be  especially  prevalent,  and  the  same 
remark  applies  in  a  lesser  degree  to  Switzerland.  In  Turkey 
and  Greece  it  is  said  to  be  less  common  (Bigler,  Boser),  while 
in  Iceland  it  is  described  as  rare  (Finsen).  Speaking  generally, 
Continental  statistics  indicate  a  much  greater  frequency  of  gastric 
carcinoma  than  those  of  Great  Britain.  The  United  States  and 
Canada  exhibit  an  ever-increasing  mortality  from  cancer,  and 
there  is  evidence  to  show  that  it  is  by  no  means  infrequent 
in   South   America    (Bey,    Gayraud   and   Domec,    Jourdanet). 


ETIOLOGY  91 

Northern  Africa,  including  Egypt,  Tunis,  Algiers,  and  Abyssinia, 
is  supposed  to  enjoy  a  special  immunity  from  the  complaint ; 
but  south  of  the  Zambesi  it  is  stated  by  competent  authorities 
to  be  extremely  frequent.  Syria,  Persia,  and  Arabia,  like  other 
countries  where  accurate  observations  are  lacking,  are  said  to 
be  comparatively  free  from  cancerous  diseases  (Polak,  Palgrave), 
while  in  most  parts  of  India  the  reverse  is  the  case.  Accord- 
ing to  Hobson,  carcinoma  in  all  its  forms  is  frequently  met 
with  in  China  ;  but  medical  missionaries  who  have  travelled  in 
the  interior  of  that  country  have  assured  us  that  cancer  of  the 
stomach  is  very  rare.1  Its  prevalence  in  Australia  and  New 
Zealand  has  already  been  commented  upon. 

5.  Topography- 
Moore  was  the  first  to  point  out  that  carcinoma  is 
more  prevalent  in  the  southern  and  eastern  parts  of  England 
than  in  the  northern  and  western  districts  ;  and  that  if  a 
line  be  drawn  across  the  country  from  Bristol  to  Peterborough, 
the  cancer  mortality  will  be  found  to  be  much  greater  to  the 
south  than  to  the  north  of  that  boundary.  At  the  present  time 
the  counties  which  present  the  highest  death-rates  from  the 
disease  are  London,  Cambridge,  Huntingdon,  Northampton, 
Sussex,  Warwick,  Bedford,  Surrey,  and  Middlesex  ;  while  those 
with  the  lowest  are  Derby,  Bucks,  Herts,  Durham,  Cornwall, 
Monmouth,  Dorset,  Lancaster,  and  parts  of  South  Wales.  These 
topographical  variations  in  the  cancer  mortality  would  appear 
from  estimates  made  by  the  Registrar- General  to  be  independent 
of  sex  and  age  distribution.  Another  interesting  fact  that  has 
been  brought  to  light  by  investigations  of  this  nature  is  that 
the  death-rate  from  the  disease  is  greater  among  rural  than 
industrial  populations,  the  inhabitants  of  country  towns  like 
Chichester,  Canterbury,  Huntingdon,  and  Cambridge  being 
more  affected  than  those  of  the  great  industrial  cities.  Haviland 
asserted  that  the  highest  cancer  mortality  is  met  with  in  low- 
lying  districts  which  are  traversed  by  sluggish  streams  and  are 
liable  to  periodic  inundations,  and  in  support  of  this  view  he 
instanced  the  Thames  and  its  tributaries,  which  run  through 
districts  that  are  markedly  cancerous.     That  there  is  probably 

1  A   similar   statement   made   by   Cantlie  of   Hong   Kong  is   cited   by  Eoger 
Williams. 


92  CANCER  OP  THE   STOMACH 

a  good  deal  of  truth  in  this  contention  is  shown  by  the  follow- 
ing remarks  of  the  Registrar-General  in  his  report  for  1890  : — 

'  Crude  death-rates  show  that  in  and  around  Huntingdon- 
shire and  Cambridgeshire  there  is  a  well-defined  area  in  which 
cancer  is  exceptionally  prevalent.  It  comprises  the  districts  of 
Stamford,  Bourn,  Spalding,  and  Holbeach  in  Lincolnshire, 
Oundle  and  Peterborough  in  Northamptonshire,  and  most 
of  the  counties  of  Huntingdon  and  Cambridge.  In  1881- 
1890  this  area  had  a  mean  population  of  over  300,000,  its 
crude  cancer-rate  being  859  per  million,  or  46  per  cent,  above 
the  average  for  the  country  in  general ;  in  the  preceding 
decennium  the  excess  was  44  per  cent.'  On  the  other  hand,  as 
Roger  Williams  has  pointed  out,  many  islands  that  have  no 
rivers,  that  are  not  low-lying  and  are  not  of  alluvial  formation, 
such  as  the  Scilly,  the  Channel  Islands,  and  the  Isle  of 
"Wight,  have  nevertheless  a  very  high  cancer  mortality.  In 
Norway  also  cancer  occurs  for  the  most  part  in  the  moun- 
tainous districts  and  at  considerable  elevations  ;  while  in  Mexico 
the  high  table-land  is  more  subject  to  the  disease  than  the  low- 
lying  plains  (Hirsch).  It  follows,  therefore,  that  whatever 
influence  a  special  district  may  exert  upon  the  development 
of  cancer,  geological  configuration  is  by  no  means  the  sole 
factor  in  its  production. 

It  has  frequently  been  noticed  that  the  inmates  of  certain 
houses  are  especially  liable  to  carcinoma,  which  appears  among 
successive  tenants  who  are  neither  related  to  one  another  nor 
possess  any  hereditary  predisposition  to  the  disease  (Arnaudet, 
Fabre,  Webb,  Fiessinger).  In  Webb's  case  a  man  died  of 
cancer  of  the  rectum  in  a  certain  house  at  the  age  of  twenty- 
six.  Of  the  next  tenants,  the  husband  died  of  gastric  cancer 
and  the  wife  of  cancer  of  the  rectum  ;  while  of  the  three  ladies 
who  next  inhabited  the  house,  one  died  from  malignant  disease 
of  the  stomach  and  another  from  a  similar  affection  of  the 
uterus.  Mason  has  also  shown  that  in  the  district  of  Leaming- 
ton the  disease  is  quite  common  in  houses  situated  in  certain 
rows  or  upon  one  side  of  a  row,  while  in  other  streets  it  is  con- 
spicuous by  its  absence.  This  writer  has  also  remarked  that 
about  17  per  cent,  of  these  cancer  houses  were  placed  at  the  end 
or  at  the  corner  of  a  street,  were  of  old  construction,  and  were 
built  upon  a  porous  subsoil.  In  this  connection  it  may  be 
noted  that  both  husband  and  wife  not  infrequently  fall  victims 


ETIOLOGY  93 

to  carcinoma  of  the  digestive  organs  if  the  survivor  continues 
to  reside  in  the  same  house,  while  occasionally  the  disease 
occurs  almost  simultaneously  in  both.!  Thus  we  have 
known  a  man  to  be  attacked  by  cancer  of  the  stomach  while 
his  wife  was  dying  from  a  similar  affection  of  the  duodenum ; 
and  also  a  man  and  his  two  daughters  to  develop  malignant 
disease  of  the  stomach  or  colon  within  a  period  of  twelve  months. 
These  several  phenomena  occur  too  frequently  to  be  regarded 
as  mere  coincidences,  and  probably  depend  upon  the  operation 
of  some  well-defined  local  cause/ the  nature  of  which,  however, 
is  still  obscure. 

6.  Race 

Want  of  evidence^renders  it  difficult  to  determine  the  exact 
influence  of  race  upon  the  inception  of  the  disease,  but  all 
the  information  we  possess  seems  to  indicate  that  savage 
peoples  enjoy  a  comparative  immunity.  In  Central  Africa  the 
negroes  appear  to  be  seldom  affected,  while  in  the  southern 
portion  of  that  continent  the  coloured  inhabitants  rarely  fall 
victims  to  the  disease,  which,  however,  is  very  rife  among  the 
white  population  and  the  crossbreeds.  Landry  found  cancer 
to  be  rare  among  the  aborigines  of  Canada,  and  it  is  also  said 
to  be  infrequent  among  those  of  New  Zealand.  According  to 
the  Tenth  Census  Report  of  the  United  States,  the  cancer  death- 
rate  was  27-96  per  100,000  whites  and  12-17  per  100,000  blacks. 

In  India  both  Mohammedans  and  Hindoos  are  equally 
affected,  while  among  the  Chinese  superficial  carcinomata  are 
common,  but  the  gastric  lesion  is  comparatively  rare.  It  is  in- 
teresting to  observe  that  in  civilised  countries  the  aliens  usually 
suffer  more  from  malignant  growths  than  those  born  in  the 
country.  Thus,  among  the  entire  population  of  Australia  over 
twenty-one  years  of  age,  Mullins  found  that  the  death-rate  from 
cancer  of  those  born  in  Germany  was  one  in  538,  of  those  born 
in  the  United  Kingdom  one  in  748,  and  of  those  born  in 
Australia  one  in  2,738.  From  these  and  other  similar  facts  he 
concluded  that  about  three-fourths  of  the  total  mortality  from 
the  disease  was  borne  by  the  immigrant  population.  The 
researches  of  Osier  and  McCrae  at  the  Johns  Hopkins  Hospital 
point  to  a  similar  conclusion,  for  they  found  that  the  native-born, 
who  constituted  78-3  per  cent,  of  the  patients,  supplied  only 
57*3  per  cent,  of  the  cases  of  gastric  cancer,  while  the  foreign- 


94  CANCEE  OF  THE   STOMACH 

born  element,  which  formed  only  21/7  per  cent,  of  the  patients, 
contributed  no  less  than  42-7  per  cent,  of  the  cases  of  that 
disease.  They  also  draw  attention  to  the  fact  that,  according  to 
the  census  of  1880,  the  death-rate  from  cancer  per  100,000  living 
was  20-08  for  the  native-born  and  53-3  for  the  foreign-born. 
Finally,  they  make  the  interesting  statement  that '  a  lower  death- 
rate  (from  carcinoma  of  the  stomach)  is  found  in  children  of 
mothers  born  in  the  United  States,  the  highest  being  in  those  of 
mothers  born  in  Germany.  This  is  most  marked  in  the  cases  over 
sixty-five  years  of  age,  being  42-72  in  children  of  native-born 
mothers  and  123-62  in  the  children  of  mothers  born  in  Germany.' 
It  has  been  asserted,  although  upon  what  authority  we  have 
been  unable  to  discover,  that  the  Jews  are  seldom  affected  by 
gastric  cancer.  Our  own  experience  has  convinced  us  that  far 
from  being  comparatively  immune,  the  Jewish  race  is  particu- 
larly prone  both  to  cancer  and  to  simple  ulcer  of  the  stomach ; 
while  according  to  Billings  the  death-rate  from  cancer  among 
the  Jews  of  the  United  States  is  the  same  as  that  of  the  rest  of 
the  white  population. 

7.  Heredity 

Statistical  inquiries  relative  to  an  hereditary  predisposi- 
tion to  cancer  *have  shown  that  in  13-22  per  cent,  of  all 
cases  of  the  disease  some  relative  of  the  patient  had  died 
from  a  malignant  growth.  With  regard  to  carcinoma  of  the 
stomach,  Lebert  found  a  family  history  of  cancer  in  7  per  cent, 
of  his  cases,  Haberlin  in  8  per  cent.,  Brautigam  in  12  percent., 
Schiile  in  6-5  per  cent.,  and  Osier  and  McCrae  in  7*3  per  cent. 
In  our  own  series,  one  or  other  parent  had  died  of  cancer  in 
6  per  cent.,  and  a  brother  or  sister  in  2  per  cent.  It  must 
be  remembered,  however,  that  all  these  figures  relate  to  hospital 
patients,  the  majority  of  whom  are  profoundly  ignorant  of  their 
family  history.  In  private  practice  a  cancerous  history  is 
obtained  in  about  16  per  cent.  The  mere  fact  that  a  patient 
with  gastric  carcinoma  was  related  to  some  one  who  died  of 
cancer  has  little  bearing  upon  the  question  of  the  hereditability 
of  the  disease,  since  one  in  every  twenty-one  men  and  one  in 
every  twelve  women  who  attain  the  age  of  thirty-five  die  of  some 
malignant  affection.  What  is  of  importance  is  the  occurrence 
of  carcinoma  of  the  same  organ  in  successive  generations. 
This  homotypic  transmission  of  the  complaint  has  so  often  been 


ETIOLOGY  95 

pointed  out  that  a  few  examples  will  suffice  to  illustrate  it. 
In  the  Bonaparte  family,  Napoleon  the  First,  his  father,  his 
brother  Lucien,  and  two  of  his  sisters,  Caroline  and  Pauline, 
all  died  of  carcinoma  of  the  stomach.  Manichow  has  recorded 
that  twenty-three  families  resident  in  one  district  had  sixty-nine 
cancerous  members  between  them,  of  whom  fifty-seven  died  of 
gastric  cancer  and  four  others  of  malignant  growths  of  the 
intestine  or  liver.  Among  our  own  cases,  the  gastric  complaint 
appeared  in  one  instance  in  three  generations,  while  in  another 
three  brothers,  their  father  and  a  sister,  all  succumbed  to  it. 
It  is  interesting  to  observe  that  the  predisposition  is  usually 
most  marked  in  children  of  the  same  sex  as  the  cancerous 
parent.  Thus,  if  the  mother  is  affected,  the  daughters  will 
exhibit  the  greatest  liability,  while  in  the  case  of  a  cancerous 
father  it  is  the  male  issue  that  are  principally  attacked.  It  is 
often  stated  that  a  family  predisposition  to  cancer  favours  its 
precocious  development ;  but  we  are  personally  of  opinion  that 
the  gastric  disease  has  a  curious  tendency  to  appear  at  the  same 
age  in  each  generation,  and  that  the  popular  superstition  upon 
this  point  has,  consequently,  a  solid  groundwork  of  fact.  It  is 
occasionally  observed  that  the  tendency  to  the  disease  is  trans- 
mitted through  some  member  of  the  family  who  had  personally 
escaped.  Thus  we  find  it  appearing  in  several  members 
of  a  family  whose  uncles,  aunts,  and  perhaps  grandparents, 
had  been  affected  in  a  similar  manner,  while  the  parent  had 
lived  to  a  great  age.  Less  frequently  a  grandparent  will 
transmit  the  disease  to  grandchildren,  while  all  the  immediate 
offspring  remain  free  from  cancer.  In  18  per  cent,  of  our  cases 
one  or  both  parents  were  stated  to  have  died  at  a  very  advanced 
age,  and  in  several  instances  the  grandparents  had  also  exceeded 
the  usual  span  of  life.  This  curious  longevity  among  the  pro- 
genitors of  cancerous  families  has  often  been  the  subject  of  com- 
ment (Eoger  Williams),  and  serves  to  emphasise  the  fact  that 
malignant  disease  is  particularly  apt  to  attack  those  who  are  con- 
sidered to  be  constitutionally  healthy.  Lastly,  it  may  be  noted 
that  persons  who  die  from  gastric  cancer  are  often  endowed  with 
great  reproductive  fecundity,  and  are  themselves  members  of 
large  families.  In  our  series  the  average  number  of  children 
was  6-6,  whereas  in  the  general  community  the  average  number 
of  a  family  is  4-6  (Fan).  Conversely,  it  is  rare  to  find  an  only 
child  attacked  by  carcinoma  of  the  stomach. 


96 


CANCEE   OF  THE   STOMACH 


8.  Occupation 

The  most  careful  inquiries  have  failed  to  show  that  occupa- 
tion exercises  any  material  influence  upon  the  development  of 
gastric  carcinoma,  while  the  fact  that  married  women  suffer 
from  the  complaint  equally  with  men  seems  to  point  to  a 
similar  conclusion.  The  following  table,  which  is  taken  from 
the  Fifty-fifth  Annual  Report  of  the  Registrar- General  of 
England,  indicates  the  relative  incidence  of  cancer  in  males 
engaged  in  different  forms  of  employment,  but  since  the 
primary  seat  of  the  disease  is  not  specified  its  conclusions  are 
not  entirely  relevant  to  the  gastric  lesion. 

Table  19. — Cancer  Deaths  in  Males.  Highest  and  Lowest  Mortality  for 
certain  Occupations,  showing  the  Comparative  Figure  to  1,000  Deaths 
from  all  Causes  (England)  ' 


Above  the  average 
[47  per  mil.] 
Occupations 

Comparative 
figure 

Below  the  average 
[47  per  mil.] 
Occupations 

Comparative 
figure 

Chimney-sweeps 

Copper-miners 

Brewers  .... 

Innkeepers  (London) 

Inn  servants    . 

Commercial  travellers 

Plasterers 

Barristers  and  solicitors  . 

Merchant  seamen    . 

Innkeepers        (industrial 

districts) 
Milk-sellers      . 
General   labourers 

(London) 
Butchers. 

156 
86 
70 
70 
67 
63 
62 
60 
60 

58 
58 

58 
57 

Medical  profes 
Miners,  all  cla 
Farmers  . 
Agricultural  la 
Gardeners 
Coalminers 
Clergymen 
Potters     . 
Grocers    . 
Hosiery-rnakei 
Lace-makers 
Lead- workers 
Coalminers  (S. 
Paper-makers 

sion  . 
sses  . 

bourers 

s 
Wales) 

43 
37 
36 
36 
36 
36 
35 
35 
34 
30 
28 
27 
26 
22 

Occupied  males  (London) 
Occupied    males   (indus- 
trial districts) 

59 

48 

All  occupied  males  . 
All  occupied  males  (agri- 
cultural districts) 

44 
40 

9.  Diet 

The  inordinate  frequency  with  which  carcinoma  attacks 
the  alimentary  canal  naturally  suggests  that  the  infective 
agent,    if    such    there    be,   is    usually    introduced    into    the 

1  In  this  table  the  mortality  of  all  males  from  twenty-five  to  sixty-five  years  of 
age  from  all  causes  is  taken  as  a  standard  =  1,000.  Out  of  this  number  the  deaths 
from  cancer  in  all  males  amount  to  forty-seven.  The  table  gives  the  comparative 
numbers  for  males  in  different  occupations,  these  numbers  having  only  a  relative, 
and  not  an  absolute,  value. 


ETIOLOGY  97 

body  with  the  food.  It  is  therefore  necessary  to  inquire 
whether  indulgence  in  or  abstinence  from  some  particular 
article  of  diet  exerts  any  decided  influence  upon  its  development. 
Eeclus  and  others  appear  to  have  convinced  themselves  that 
those  who  live  upon  vegetables  are  practically  exempt  from 
the  disease,  but  the  evidence  upon  which  this  belief  is  founded 
is  somewhat  obscure.  On  the  other  hand,  there  are  strong 
reasons  for  believing  that  the  exclusive  use  of  vegetables  does 
not  prevent  the  inception  of  cancer.  Hendley  states  that  out 
of  102  patients  who  were  operated  upon  for  carcinoma  at 
Jeypore  between  1880  and  1888,  sixty- one  were  lifelong 
vegetarians  ;  while  nearly  3  per  cent,  of  oar  cases  of  gastric 
carcinoma  denied  that  they  had  eaten  meat  for  many  years. 
In  private  practice  we  have  also  frequently  observed  the 
disease  in  people  who  had  long  abstained  from  animal  food. 
The  popular  superstition  that  tomatoes  give  rise  to  cancer  is 
probably  founded  upon  some  fancied  resemblance  between 
the  interior  of  the  vegetable  and  a  fungoid  growth.  Other 
authorities  attribute  the  increase  of  carcinoma  to  the  greater 
consumption  of  meat  by  the  population  during  the  last  half- 
century.  It  can  hardly  be  denied  that  the  tendency  to 
luxurious  living  has  increased  in  almost  every  country  in  the 
last  fifty  years,  but  that  excessive  indulgence  in  meat  is  a 
primary  factor  in  the  production  of  the  disease  has  yet  to  be 
proved.  It  may  be  noted  that  the  liability  to  cancer  of  the 
stomach  increases  with  age,  whereas  the  appetite  for  meat 
usually  diminishes  after  middle  life.  Moreover,  it  is  almost 
unknown  among  savage  tribes,  who  live  by  hunting,  and  among 
the  Esquimaux,  while  it  is  common  both  in  hospitals  and 
infirmaries,  whose  sick  inmates  have  seldom  enjoyed  oppor- 
tunities for  over-indulgence  in  meat. 

Again,  there  is  no  evidence  to  show  that  any  special  variety 
of  animal  food  promotes  the  development  cf  the  complaint. 
Dried  and  tinned  foods  are  apparently  harmless,  and  Bauby 
has  shown  that  pork-eaters  are  not  more  prone  to  the  disease 
than  others.  It  has  been  suggested  that  the  importation  of 
frozen  mutton  might  be  responsible  for  the  increasing  prevalence 
of  malignant  disease  in  Europe  ;  but  the  comparative  immunity 
enjoyed  by  the  native  populations  of  Australia  and  Argentina, 
and  the  uniform  increase  of  the  disease  hi  all  parts  of  the 
civilised    world,    are    sufficient    to    negative   this    supposition. 

H 


98  CANCEE  OF  THE   STOMACH 

Fishermen  in  England  are  unduly  prone  to  cancer,  but  this 
can  hardly  be  ascribed  to  their  diet,  since  the  disease  is  very 
common  in  the  Black  Forest  and  other  parts  of  Central  Europe 
where  fish  is  a  rare  article  of  food. 

It  is  often  asserted  that  teetotalers  are  seldom  affected  by 
carcinoma,  but  we  are  not  aware  of  any  authentic  evidence  in 
support  of  this  view.  On  the  contrary,  we  find  that  nearly  40 
per  cent,  of  our  cases  at  the  London  Temperance  Hospital 
were  total  abstainers ;  while  at  the  London  Hospital,  where 
patients  are  very  seldom  given  to  abstinence,  no  less  than 
4  per  cent,  of  the  cases  of  gastric  cancer  affirmed  that  they 
had  been  lifelong  abstainers  from  alcohol.  It  may  also  be 
noted  that  malignant  disease  is  very  common  among  the 
Mohammedan  population  of  India,  who  never  indulge  in 
alcohol ;  while  the  British  Medical  Association's  report  upon 
the  etiology  of  cancer  indicates  that  the  alcoholic  habit  is, 
if  anything,  antagonistic  to  the  development  of  carcinoma. 
Lastly,  Boger  Williams  has  laid  great  stress  upon  the  tendency 
of  the  complaint  to  attack  people  who  have  led  sober  and  in- 
dustrious lives,  and  upon  the  comparative  immunity  of  those  of 
debauched  and  dissolute  habits.  We  are  also  convinced  that 
the  gastric  lesion  is  extremely  rare  among  persons  affected  with 
alcoholic  gastritis,  cirrhosis  of  the  liver,  and  nervous  com- 
plaints due  to  chronic  alcoholism.  Although,  therefore,  it  is 
possible  that  the  abuse  of  stimulants  may  so  diminish  the 
natural  resistance  of  the  tissues  as  to  favour  the  inception 
of  cancer,  as  it  undoubtedly  does  that  of  tubercle,  we  do  not 
believe  that  it  is  in  any  way  an  important  factor.  Cloquet  has 
attributed  the  prevalence  of  cancer  of  the  stomach  in  certain 
parts  of  Normandy  to  the  consumption  of  acid  cider,  while 
Brunon  and  Rebulet  regard  the  frequent  admixture  of  sea 
water  with  that  local  drink  as  the  deleterious  agent.  Neither 
of  these  views,  however,  has  been  endorsed  by  the  committee 
appointed  to  investigate  the  subject,  which  seems  to  have 
considered  that  heredity  was  the  principal  cause  of  the  pre- 
valence of  the  complaint. 

Although  indulgence  in  meat  or  alcohol  does  not  appear  to 
favour  the  inception  of  carcinoma,  it  is  quite  possible  that  the 
mischief  may  be  due  to  the  inordinate  consumption  of  some  other 
article  of  diet.  A  comparative  study  of  the  food  of  savage  and 
civilised  communities  at  once  indicates  that  at  least  two 
common  articles  of  diet  are  usually  wanting  among  those  who 


ETIOLOGY 


99 


appear  to  be  naturally  exempt  from  malignant  disease.  The 
first  of  these  is  bread  made  with  yeast,  and  the  other  beer.  It 
is  also  a  curious  fact  that  among  the  poorest  agricultural  popu- 
lations, where  these  two  products  of  civilisation  are  rarely 
employed,  carcinoma  is  supposed  to  be  rare,  while  in  those 
districts  where  one  or  other  is  taken  in  excess  the  complaint  is 
exceptionally  common.1  It  is  also  interesting  to  observe  that 
modern  pathologists  are  inclined  to  regard  the  cell-enclosures 
met  with  in  carcinoma  as  more  closely  allied  to  yeast  than  to 
protozoa,  and  should  this  identity  be  established  it  will  cer- 
tainly be  advisable  to  ascertain  whether  all  or  only  a  portion  of 
the  fungus  employed  in  the  preparation  of  bread  and  beer  is 
really  killed  in  the  process  of  manufacture. 

10.  Hygiene 
The  frequent  occurrence  of  carcinoma  of  the  stomach  in  old 
houses  and  in  those  whose  drainage  systems  are  defective  has 
led  to  the  belief  that  insanitary  conditions  either  predispose 
to  or  excite  the  disease.2  It  would  appear,  however,  from 
the  reports  of  the  Eegistrar-General  that  the  death-rate  from 
cancer  is  comparatively  low  in  densely  populated  districts, 
where  the  hygienic  arrangements  are  imperfect  and  where  the 
mortality  from  infectious  complaints  is  the  greatest.  It  is 
also  less  among  those  engaged  in  industrial  employments 
than  among  the  professional  classes  and  shopkeepers;  while 
m  most  of  the  large  cities  it  is  more  prevalent  in  the  wealthy 
quarters  than  in  those  of  the  poorer  section  of  the  population. 
These  facts  have  induced  certain  authorities  to  regard  luxuri- 
ous living  as  an  important  factor  in  the  etiology  of  malignant 
disease,  but  it  might  also  be  argued  that  the  lesser  mortality 
m  early  life  among  the  rich  permits  a  greater  proportion  to 
attain  the  age  at  which  cancer  is  usually  met  with. 

11.  Traumatism  and  Mental  Conditions 

Carcinoma  of   the   stomach    occasionally  follows  a  severe 
blow  upon  the  epigastrium,  just  as  an   injury  to   the  breast 

1  Table  19  indicates  that  brewers,  inn-servants,  innkeepers,  and  commercial 
travellers  are  unduly  prone  to  cancer;  while  the  prevalence  of  the.  disease  among 
those  exposed  to  soot  and  the  products  of  copper-smelting  suggests  the  possible 
influence  of  arsenic  as  a  predisposing  cause. 

z  Mason  found  that  defective  drainage  existed  in  25-7  per  cent,  of  the  houses 
where  the  disease  occurred. 


n  2 


100 


CANCER  OF  THE   STOMACH 


sometimes  forms  the  starting-point  of  the  disease  in  that  organ. 
It  is  probable,  however,  that  in  both  cases  the  effect  of  traumatism 
is  to  determine  the  location  of  the  growth  rather  than  actually 
to  produce  it,  much  in  the  same  way  that  an  injury  in  a  tuber- 
culous subject  is  apt  to  be  followed  by  a  local  manifestation 
of  the  complaint.  There  are  also  a  few  instances  on  record  in 
which  a  cancerous  tumour  of  the  stomach  was  found  to  contain 
a  pin,  a  spicule  of  bone,  or  some  other  foreign  body  that  had 
become  embedded  in  the  gastric  wall  and  had  given  rise  to 
chronic  irritation  of  the  tissues. 

The  older  writers  were  wont  to  regard  grief  and  mental 
trouble  as  important  factors  in  the  production  of  cancer,  but  of 
recent  years  these  and  similar  views  seem  to  have  fallen  into 
disrepute.  No  practitioner,  however,  who  has  had  much 
experience  of  cancer  of  the  digestive  tract  can  fail  to  have 
been  struck  by  its  extreme  frequency  in  men  who  have  been 
subjected  to  great  domestic  trouble ;  and,  for  our  own  part, 
we  are  so  convinced  that  continued  mental  worry  is  a  pre- 
disposing cause  of  the  disease  that  we  make  it  a  subject  of 
inquiry  in  every  case,  and  regard  its  existence  as  a  fact  of  clinical 
importance. 


12.  Influence  of  Seasons 

In  the  following  table  we  have  arranged  154  cases  of  carci- 
noma of  the  stomach  according  to  the  month  in  which  the 
disease  terminated  and  that  in  which  it  was  supposed  to  have 
commenced. 

Table  20 


Fatal  cases    Percentage 


December 

January 

February 

March 

April 

May 

June 

July 

August 

September 

October . 

November 


Admissions 
to  hospital 


9, 
6 '  22 

V 

10, 

13  -  37 
14) 

14  I 

18  '-  42 

10' 

18 ) 

19  53 

16) 


14-3 

10  -  22 

V 

18, 

24 

15  ,  41 

81 

16, 

27-2 

19  -  45 

io) 

15, 

344 

18  44 

11' 

14-4 
27 
29-6 
29 


26  [  53 
19  J 

2I 
25-30 

3  J 

13  r  26 
81 
12 
11'  30 

1) 


38 
21-6 
18-7 
21-6 


ETIOLOGY  101 

We  have  given  preference  to  the  lethal  event  because  the 
accuracy  of  the  figures  upon  this  point  is  beyond  dispute, 
whereas  those  that  refer  to  the  commencement  of  the  complaint 
are  always  open  to  doubt.  It  will  be  observed  that  the  death- 
rate  varies  at  different  times  of  the  year,  being  lowest  during 
December,  January,  and  February,  and  highest  in  September, 
October,  and  November  ;  or  if  the  months  be  grouped  according 
to  seasons,  that  over  60  per  cent,  of  the  total  deaths  take  place 
between  June  and  November.  These  figures  are,  of  course,  too 
small  to  warrant  any  absolute  conclusions  being  drawn  from 
them,  but  at  the  same  time  they  are  too  striking  to  be  ignored, 
more  especially  as  both  Yirchow  and  d'Espine  noticed,  fifty 
years  ago,  that  persons  affected  with  malignant  disease  die  more 
frequently  in  the  summer  than  in  the  winter.  This  fact  is  of 
itself  somewhat  curious,  since  one  would  have  supposed  that  a 
disease  which  reduces  the  vitality  to  such  a  low  ebb,  and  so 
often  terminates  by  pneumonia,  would  be  more  likely  to  prove 
fatal  to  the  poor  inhabitants  of  London  during  the  cold  and  wet 
winter  months  than  in  the  more  genial  weather  of  the  summer 
and  autumn.  At  first  sight  it  would  seem  as  if  an  increase  of  the 
temperature  of  the  air  might  stimulate  the  growth  of  a  malignant 
tumour,  in  the  same  way  that  it  does  that  of  plants,  and  by 
accelerating  its  progress  curtail  the  period  of  existence.  That 
an  increased  rapidity  of  growth  really  does  take  place  during 
the  spring  and  summer  is  more  than  probable,  for  not  only  do 
cases  succumb  more  quickly  between  April  and  August,  but,  as 
will  be  seen  from  the  table,  only  about  one-seventh  of  the  total 
number  were  admitted  into  hospital  during  December,  January, 
and  February.  Personally,  however,  we  are  strongly  of  opinion 
that  carcinoma  obeys  certain  laws  of  epidemiology,  like  enteric 
fever,  acute  rheumatism,  and  other  infective  diseases,  and  is 
consequently  more  rife  at  certain  seasons  than  at  others.  If  it 
be  allowed  that  the  usual  duration  of  the  gastric  complaint 
varies  from  nine  to  twelve  months,  we  should  expect  from  the 
facts  already  noted  that  in  the  majority  of  the  cases  it  would 
commence  between  September  and  February;  and  in  this 
connection  the  last  part  of  the  table  becomes  instructive,  for  it 
will  be  observed  that  in  60  per  cent,  of  the  entire  number  the 
first  symptoms  of  illness  showed  themselves  within  that  period. 
We  venture  to  believe  that  further  investigation  upon  these  lines 
will  throw  an  important  light  upon  the  etiology  of  carcinoma. 


102  CANCEE  OF  THE   STOMACH 

13.  Influence  of  Other  Diseases 

(a)  Gastric  Ulcer. —  Cruveilhier  was  the  first  to  point  out 
that  carcinoma  is  apt  to  attack  the  edge  or  scar  of  a  simple 
ulcer,  and  the  subsequent  confirmation  of  this  fact  by  Eoki- 
tansky,  Dittrich,  Brinton,  and  Hauser  has  led  to  the  belief  that 
a  causal  relationship  exists  between  the  two  complaints.  Thus, 
according  to  Lebert,  9  per  cent,  of  all  gastric  cancers  originate  in 
this  manner ;  but  Rosenheim  is  disposed  to  reduce  this  estimate 
to  6  per  cent,  and  Haberlin  to  2-3  per  cent.  The  widespread 
destruction  of  the  tissues  that  results  from  a  malignant  growth 
usually  obliterates  every  trace  of  a  pre-existent  ulcer  or  scar,  and 
it  is  therefore  necessary  to  surmise  the  former  presence  of  such 
a  lesion  from  a  history  of  severe  pain  or  hseniateraesis.  Out  of 
134  cases  in  which  special  inquiries  were  directed  by  us  to  this 
question,  only  four,  or  3  per  cent.,  admitted  having  suffered  from 
symptoms  of  this  kind  prior  to  the  onset  of  the  fatal  complaint. 
As  this  result  tallies  closely  with  our  experience  in  private 
practice,  we  are  inclined  to  believe  that  not  more  than  3  per 
cent,  of  all  cases  of  gastric  cancer  are  preceded  by  simple  ulcer. 
Even  this,  however,  does  not  necessarily  imply  that  the  benign 
predisposes  to  the  malignant  affection,  for,  inasmuch  as  nearly 
5  per  cent,  of  the  entire  population  suffer  at  one  period  or 
another  from  ulceration  of  the  stomach,  the  two  diseases  must 
frequently  occur  in  the  same  individual.  It  seems  to  us  most 
probable  that  a  simple  ulcer,  like  any  other  local  injury,  merely 
helps  to  determine  the  location  of  the  growth  in  a  cancerous 
subject ;  and  in  support  of  this  view  it  may  be  noted  that  while 
a  healthy  stomach  rarely  becomes  the  seat  of  metastatic  growths, 
this  immunity  largely  disappears  if  the  organ  happens  to 
present  a  chronic  ulcer. 

(b)  Functional  Disorders  of  the  Stomach. — Chronic  gastritis 
does  not  appear  to  favour  the  growth  of  carcinoma,  while  the 
alcoholic  variety  is,  if  anything,  inimical  to  its  development. 
Functional  disturbances  are  also  rarely  followed  by  the  disease. 
Out  of  134  of  our  cases  in  which  details  as  to  the  previous 
health  of  the  patients  were  noted,  only  16  per  cent,  were  men- 
tioned as  having  suffered  from  any  dyspeptic  ailment  before 
the  symptoms  of  malignant  disease  presented  themselves.  Of 
nineteen  persons  who  were  the  subjects  of  cancer  of  the  cardia 
there  was  a  history  of  dyspepsia  in  only  one,  who  was  said  to 


ETIOLOGY  103 

have  been  liable  to  '  bilious  attacks.'  Out  of  thirty-one  in  whom 
the  body  of  the  organ  was  the  seat  of  the  new  growth,  two  had 
been  subject  to '  bilious  attacks,'  in  one  a  simple  chronic  ulcer  was 
discovered  after  death,  and  three,  or  9  per  cent.,  had  occasionally 
suffered  from  some  form  of  indigestion.  Among  eighty-four 
cases  of  cancer  of  the  pylorus,  fifteen,  or  17  per  cent.,  were 
recorded  as  having  previously  suffered  from  gastric  derange- 
ment ;  but  of  these  two  had  only  been  liable  to  '  bilious  attacks,' 
in  one  a  chronic  ulcer  was  discovered  after  death,  in  three  pain 
after  food  and  hsematemesis  pointed  to  gastric  ulcer  as  the  pro- 
bable cause  of  the  trouble,  while  two  had  been  liable  to  biliary 
colic  and  biliary  calculi  were  found  on  post-mortem  examination. 
From  the  above  facts  we  conclude  that  carcinoma  rarely 
affects  those  who  have  been  the  subjects  of  chronic  dyspepsia ; 
that  when  such  is  the  case  the  pyloric  region  is  usually  the 
seat  of  the  new  growth  ;  and  that  the  symptoms  of  the  ante- 
cedent disorder  may  often  be  traced  either  to  simple  ulcer  or  to 
gallstones. 

(c)  Benign  Growths. — Persons  who  present  innocent 
tumours  of  the  skin  or  internal  viscera  are  not  especially  prone 
to  carcinoma  of  the  stomach.  Among  our  fatal  cases  of  that 
complaint,  uterine  fibro-myomata  were  only  present  in  3  per 
cent,  and  a  cyst  of  the  ovary  in  0'5  per  cent,  of  the  females, 
while  no  instance  of  adenoma  of  the  breast  was  recorded. 
Observations  as  to  the  existence  of  warts,  lipomata,  and  other 
benign  tumours  are  wanting  in  our  hospital  statistics,  but  from 
our  own  observations  we  are  inclined  to  believe  that  these  and 
other  benign  tumours  are  rare  in  the  subjects  of  malignant 
disease  of  the  stomach.  Carcinoma  has  been  occasionally  found 
associated  with  adenomata  of  the  stomach,  but  the  attempt 
by  Menetrier  to  establish  a  causal  connection  between  the  two 
can  hardly  be  said  to  have  been  successful. 

(d)  Tuberculosis.— The  frequency  of  obsolete  tubercle  in 
persons  who  have  died  from  gastric  cancer  has  often  been  the 
subject  of  remark.  In  our  own  series  one  or  both  lungs 
presented  signs  of  former  tuberculosis  in  15-8  per  cent.,  while 
Lebert  observed  a  similar  condition  in  14-7  per  cent,  of  his 
cases.  Although  estimates  relative  to  the  frequency  of  the 
pulmonary  lesion  among  persons  who  have  died  from  all  causes 
vary  from  4-7  per  cent.  (Heitler)  to  44  per  cent.  (Schlenker),  it  is 
probable  that  of  all  diseases  carcinoma  is  most  often  associated 


104  CANCEE  OF  THE   STOMACH 

with  obsolete  tubercle.  On  the  other  hand,  most  authorities  are 
agreed  that  the  two  complaints  rarely  coexist  in  an  active  state 
in  the  same  individual,  and  that  when  carcinoma  commences  the 
tubercle  usually  ceases  to  progress.  In  one  case  of  this  kind, 
which  we  were  able  to  wTatch  throughout  its  course,  a  rapid 
tuberculosis  of  the  lungs  and  intestines  came  suddenly  to  a  halt 
when  symptoms  of  malignant  disease  of  the  stomach  and 
pancreas  made  their  appearance,  and  after  death,  at  the  end  of 
eight  months,  not  only  wras  the  pulmonary  lesion  found  to  be 
completely  quiescent,  but  more  than  thirty  ulcers  in  the  bowel 
had  either  partially  or  entirely  cicatrised.  It  is  probable,  there- 
fore, that  while  the  two  diseases  are  not  wholly  incompatible,  the 
tubercle  bacillus  is  unable  to  flourish  in  the  same  body  as 
carcinoma.  On  the  other  hand,  there  is  evidence  to  show  that 
a  proclivity  to  tuberculosis  distinctly  favours  the  inception  of 
cancer.  Among  the  general  community  a  family  history  of 
tubercle  exists  from  108  (Dovey)  to  28*5  per  cent.  (Kuthy), 
while  Roger  Williams  found  a  similar  history  in  50  per  cent, 
of  his  cases  of  uterine  and  mammary  cancer,  and  26  per  cent. 
of  our  gastric  cases  possessed  one  or  more  near  relatives  who 
had  succumbed  to  phthisis.  It  is  also  interesting  to  observe 
that  the  progenitors  of  cancerous  families  are  often  themselves 
the  sole  survivors  of  tuberculous  families,  and  that  while  the 
cancerous  proclivity  shows  itself  most  often  in  the  elder  children 
(Moore),  the  younger  ones  not  infrequently  succumb  to  con- 
sumption. In  other  instances  cancer  and  phthisis  alternate  in 
successive  generations. 

(e)  Rheumatism. — Rather  more  than  8  per  cent,  of  our 
cases  had  suffered  from  acute  rheumatism  in  early  life,  and  in 
about  7  per  cent,  there  was  evidence  of  disease  of  the  mitral  or 
aortic  valves.  Considering  how  common  rheumatism  is  among 
the  inhabitants  of  the  East-end  of  London,  this  proportion 
cannot  be  considered  excessive. 

(/)  Malaria,  and  Syphilis. — It  has  been  asserted  that  carci- 
noma is  rare  in  malarious  districts,  and  that  those  who  have 
suffered  from  ague  are  seldom  afflicted  with  malignant  disease. 
For  such  statements,  however,  we  can  find  no  justification.  In 
England,  one  of  the  principal  cancer  districts  is  situated  in  those 
regions  where  malaria  is  chiefly  encountered,  and  we  have  been 
assured  by  competent  observers  that  in  Africa  men  who  have  had 
many  attacks  of  fever  are  in  no  way  exempt  from  cancer.     Owing 


ETIOLOGY  105 

to  its  situation  near  the  docks,  cases  of  malaria  are  frequently 
admitted  into  the  London  Hospital,  and  our  series  of  deaths 
from  carcinoma  of  the  stomach  includes  no  fewer  than  eight 
men  who  had  previously  suffered  from  malaria.  It  is  noteworthy 
that  in  two  of  these  the  malignant  disease  ran  its  course  in  less 
than  five  months.  Several  writers  have  remarked  upon  the 
comparative  rarity  of  syphilis  among  the  subjects  of  carcinoma, 
and  our  own  experience  is  confirmatory  of  this.  Of  our  hospital 
cases,  only  6  per  cent,  of  the  men  had  apparently  suffered  from 
the  disease,  which  is  a  very  small  proportion  for  the  district 
from  which  they  were  drawn. 

(g)  Apoplexy  and  Insanity.  —No  particular  stress  can  be 
laid  upon  the  somewhat  excessive  frequency  of  cerebral  haemor- 
rhage among  the  progenitors  of  those  who  die  from  gastric 
cancer,  since  many  of  them  lived  to  an  extreme  old  age.  On 
the  other  hand,  there  seems  to  be  a  distinct  connection  between 
insanity  and  malignant  disease,  possibly  through  their  mutual 
association  with  tuberculosis.  Both  melancholia  and  mania 
occasionally  develop  during  the  course  of  the  gastric  com- 
plaint, and  in  such  cases  there  is  usually  a  history  of  tuber- 
culosis or  insanity  in  the  family. 


106  CANCEE  OP  THE   STOMACH 


CHAPTEE   IV 

SYMPTOMATOLOGY 

There  are  few  diseases  which  at  an  early  period  of  their 
course  are  more  difficult  to  recognise  than  cancer  of  the  stomach. 
The  pain,  vomiting,  and  haemorrhage  that  are  usually  regarded 
as  especially  indicative  of  the  complaint  may  not  only  be 
entirely  absent,  but  occasionally  exhibit  such  individual  promi- 
nence as  to  suggest  some  other  and.  less  serious  affection  of  the 
digestive  organs.  In  other  cases  the  existence  of  intense 
anaemia,  accompanied  by  fever  and  general  debility,  appears  to 
indicate  a  disorder  of  the  blood-making  viscera ;  while  in  not  a 
few  the  symptoms  which  arise  from  secondary  implication  of 
the  liver  or  peritoneum  completely  mask  those  of  the  original 
complaint. 

In  order  to  obtain  a  clear  comprehension  of  the  disease  in 
its  protean  aspects  it  is  necessary  not  only  to  study  the  clinical 
features  of  a  large  number  of  cases,  but  to  compare  the  various 
symptoms  presented  by  each  with  the  nature,  location,  and 
distribution  of  the  growth  as  determined  after  death.  A  writer 
who  trusts  solely  to  his  own  experience,  however  extensive  that 
may  have  been,  can  hardly  fail  to  be  biassed  by  the  recollection 
of  certain  cases  which  from  some  cause  or  another  were  unduly 
impressed  upon  his  mind. ;  while  he  who  formulates  his  ideas 
from  a  series  of  isolated  examples,  collected,  from  the  periodical 
literature,  courts  every  error  that  is  inherent  in  an  unverified 
diagnosis. 

In  order  to  avoid,  as  far  as  possible,  these  sources  of  error, 
we  have  based,  our  clinical  description  of  the  disease  upon  the 
details  afforded  by  154  cases  which  were  treated  and  carefully 
examined  after  death  at  the  London  Hospital  and  the  London 
Temperance  Hospital  between  1893  and  1900.  It  will  be  readily 
understood  that,  owing  to  the  difficulty  of  securing  complete 


SYMPTOMATOLOGY  107 

uniformity  in  the  record  of  the  various  symptoms,  the  entire 
number  is  not  always  available  for  the  investigation  of  every 
point  of  interest. 

(1)  Mode  of  Onset. — It  is  the  usual  custom  to  describe  the 
commencement  of  the  complaint  as  insidious,  and  in  the  majority 
of  the  cases  it  is  undoubtedly  true  that  the  local  phenomena 
remain  obscure  until  the  morbid  growth  has  either  given  rise 
to  obstruction  of  an  orifice  or  has  undergone  ulceration.  We 
find,  however,  that  in  9  per  cent,  of  our  cases  the  initial  sym- 
ptoms were  stated  to  have  appeared  quite  suddenly  ;  and  since 
in  every  instance  there  seems  to  have  been  considerable  diffi- 
culty of  diagnosis,  it  is  advisable  briefly  to  consider  this  unusual 
mode  of  development. 

An  abrupt  onset  may  be  marked  by  three  varieties  of 
symptoms.  As  a  rule  the  patient  is  attacked  by  acute  gastritis, 
which,  instead  of  subsiding  under  treatment,  assumes  a  subacute 
or  chronic  character  and  continues  throughout  the  whole  course 
of  the  complaint.  Less  frequently  the  first  indication  of  illness 
consists  of  severe  epigastric  pain,  which  either  persists  more  or 
less  constantly,  or  assumes  a  paroxysmal  character  and  is 
aggravated  by  food.  Finally,  in  rare  instances  a  profuse 
hgematemesis,  like  that  which  occurs  in  simple  ulcer,  is  the  first 
symptom  to  attract  attention. 

(a)  When  the  symptoms  of  acute  gastritis  usher  in  the 
disease,  they  are  generally  attributed  by  the  patient  either  to 
over-indulgence  in  some  article  of  food  or  drink,  or  to  the  im- 
bibition of  cold  water  or  beer.  In  other  cases  exposure  to  cold, 
an  attack  of  influenza,  over-fatigue,  excitement,  or  mental  worry 
is  regarded  as  the  exciting  cause  of  the  complaint.  Since, 
however,  in  every  instance  of  this  kind  the  pylorus  is  found  to 
be  obstructed  after  death,  it  is  probable  that  the  inflammatory 
disorder  was  really  the  outcome  of  retention  and  decomposition 
of  the  food.  The  general  features  of  the  illness  are  well  shown 
in  the  following  case. 

Case  I.  A  medical  man,  aged  forty-three,  engaged  in  a  large 
practice  in  London,  consulted  us  in  October  1895  for  indigestion. 
He  stated  that  he  had  been  perfectly  well  until  the  9th  of  September, 
when,  after  attending  a  public  dinner  and  eating  more  than  was  his 
habit,  he  felt  very  unwell  and  vomited  a  large  quantity  of  undigested 
food.  After  taking  the  usual  remedies  and  restricting  his  diet  for  a 
day  or  two,  he  found  that  instead  of  recovering  the  power  of  digestion 


108  CANCEE  OF  THE   STOMACH 

he  was  unable  to  take  solid  food  without  discomfort,,  and  within  a 
week  was  obliged  to  confine  himself  to  milk  and  other  liquid 
forms  of  nourishment.  Since  that  time  he  had  constantly  suffered 
from  nausea,  flatulence,  and  acidity,  had  grown  very  weak,  and  had 
lost  nine  pounds  in  weight.  On  examination  the  stomach  was  found 
to  be  slightly  dilated,  and  to  contain  a  large  excess  of  mucus,  but  no 
free  hydrochloric  or  lactic  acid.  No  tumour  could  be  detected,  nor 
was  there  any  evidence  of  disease  in  the  other  organs  of  the  body. 
But  in  spite  of  the  most  careful  dieting  and  medicinal  treatment, 
flatulence,  acidity,  and  nausea  ensued  after  every  meal,  and  within  a 
few  weeks  a  strong  aversion  to  food  manifested  itself.  When  seen  a 
month  later  the  patient  was  found  to  have  lost  nearly  a  stone  in 
weight,  and  appeared  extremely  weak.  The  dilatation  of  the  stomach 
was  now  marked,  and  its  contents  exhibited  an  abundance  of  lactic 
acid.  There  was  also  complaint  of  constant  micturition,  and  on 
examining  the  pelvis  a  tender  mass  about  the  size  of  a  walnut  could 
be  felt  between  the  rectum  and  the  bladder.  Six  weeks  later  the 
debility  had  increased  so  much  that  we  found  him  confined  to  bed. 
Nausea  and  vomiting  ensued  about  an  hour  after  every  meal,  and  the 
bladder  symptoms  were  very  troublesome.  The  abdomen  was  dis- 
tended and  contained  a  small  quantity  of  free  fluid,  while  several 
indefinite  tumours  could  be  felt  near  the  umbilicus  and  in  the  left 
iliac  fossa.  Death  occurred  almost  exactly  five  months  after  the 
onset  of  the  acute  symptoms,  and  at  the  autopsy  there  was  found 
colloid  infiltration  of  the  pyloric  half  of  the  stomach,  with  implication 
of  the  omentum  and  pelvic  peritoneum. 

(b)  When  acute  pain  constitutes  the  first  indication  of  the 
disease,  the  growth  is  usually  localised  to  a  comparatively  small 
area  of  the  stomach,  and  is  found  after  death  to  be  extensively 
ulcerated.  It  is  probable,  therefore,  that  sudden  sloughing  of 
its  substance  was  the  cause  of  the  symptom  in  question.  Not 
infrequently  the  pain  develops  soon  after  some  physical  effort, 
when  the  patient  feels  as  though  something  had  given  way  in 
his  abdomen,  and  is  seized  with  faintness  and  vomiting. 
Subsequently  the  suffering  is  more  or  less  continuous,  and  is 
especially  severe  after  meals  or  upon  exertion.  The  following 
case  is  a  good  example  of  this  mode  of  onset. 

Case  II.  A  labourer,  aged  fifty-two,  was  admitted  into  the 
London  Temperance  Hospital  for  severe  pain  in  the  epigastrium  of 
six  weeks'  duration.  He  stated  that  one  afternoon,  while  lifting  a 
heavy  weight,  he  had  been  seized  with  violent  pain  in  the  belly,  which 
caused  him  to  feel  faint  and  to  vomit.     The  pain  continued  intense 


SYMPTOMATOLOGY  109 

for  three  days,  after  which  it  subsided  somewhat,  but  was  always 
increased  by  the  ingestion  of  food.  Since  the  commencement  of  the 
illness  he  had  lost  more  than  a  stone  in  weight  and  had  become  very 
weak.  On  examination  the  patient  was  observed  to  be  much 
emaciated.  The  lower  border  of  the  stomach  extended  to  the 
umbilicus,  and  immediately  above  and  to  the  right  of  that  spot  an 
indistinct  and  tender  tumour  could  be  felt.  The  gastric  contents 
were  devoid  of  free  hydrochloric  acid  but  rich  in  lactic  acid.  The 
general  condition  rapidly  deteriorated,  and  even  milk  soon  gave  rise 
to  pain.  At  the  end  of  a  month  a  secondary  nodule  was  detected  in 
the  right  lobe  of  the  liver,  and  death  ensued  from  exhaustion  about 
fourteen  weeks  after  the  onset  of  the  pain.  The  autopsy  revealed  a 
malignant  ulcer  of  the  spheroidal-cell  type,  situated  on  the  lesser 
curvature,  close  to  the  pylorus,  with  secondary  growths  in  the  liver 
and  cceliac  glands. 

(c)  Profuse  hcematemesis  as  an  initial  symptom  is  practically 
confined  to  ulcerating  growths  of  the  pylorus  or  cardia.  Both 
in  its  quantity  and  general  appearance  the  haemorrhage  closely 
resembles  that  of  simple  ulcer,  and  the  case  is  usually  regarded 
as  an  example  of  that  disease  until  the  continuous  loss  of  flesh, 
anorexia,  and  increasing  discomfort  after  food,  lead  to  the 
suspicion  of  a  malignant  affection. 

Case  III.  A  man,  aged  fifty-five,  was  admitted  into  the  London 
Temperance  Hospital  with  the  diagnosis  of  chronic  gastric  ulcer.  It 
appeared  from  his  history  that  he  had  been  perfectly  well  until  four 
months  previously,  when  after  supper  one  evening  he  suddenly  turned 
faint  and  vomited  a  chamberful  of  bright  blood.  After  remaining  in 
bed  for  several  weeks  he  tried  to  resume  his  former  mode  of  life,  but 
found  that  he  had  lost  a  great  deal  of  flesh  and  was  unable  to  take 
any  solid  food  without  experiencing  pain  in  the  epigastrium.  Vomit- 
ing occurred  occasionally  at  night,  and  the  emaciation  made  rapid 
progress.  On  admission  the  stomach  was  found  to  reach  two  inches 
below  the  level  of  the  umbilicus,  and  the  peristaltic  movements  of 
the  viscus  were  clearly  visible  through  the  attenuated  parietes.  No 
tumour  could  be  detected,  but  as  a  result  of  a  test  meal  the  gastric 
contents  were  shown  to  be  devoid  of  free  hydrochloric  acid.  Despite 
lavage  and  careful  dieting  he  grew  steadily  worse,  and  died  five  weeks 
after  admission.  The  necropsy  revealed  scirrhous  carcinoma  of  the 
pylorus  with  extensive  ulceration. 

In  all  cases  where  the  disease  appears  to  begin  in  an  acute 
manner,  it  will  be  observed  that  the  physical  signs  show  that 
the  growth  has  already  made  considerable  progress,  while  the 


110  CANCEE  OF  THE   STOMACH 

total  period  covered  by  the  subjective  symptoms  seldom  exceeds 
more  than  a  few  months. 

(2)  Pain. — Malignant  diseases  are  so  often  accompanied  by 
pain  that  it  might  reasonably  be  expected  that  a  cancerous 
growth  in  a  highly  organised  structure  like  the  stomach 
would  be  associated  with  considerable  suffering.  In  the 
majority  of  cases  pain  certainly  constitutes  the  most  prominent 
of  the  local  symptoms  ;  but  occasionally  it  is  conspicuous  by  its 
absence,  not  only  at  the  commencement,  but  throughout  the 
whole  course  of  the  malady.  Brinton  estimated  the  frequency 
of  these  painless  cases  at  8  per  cent.,  and  Lebert  at  25  per 
cent.,  while  in  14  per  cent,  of  those  in  our  hospital  series  it 
was  stated  that  pain  was  either  absent  altogether  or  extremely 
slight.  As  this  latter  figure  tallies  with  the  experience  of 
Osier  and  McCrae  (13-3  per  cent.),  we  are  inclined  to  adopt  it 
as  the  nearest  to  the  truth.  The  pain  varies  greatly,  not  only 
in  different  cases,  but  also  in  the  same  individual  at  different 
times,  being  sometimes  aching  or  burning  in  character, 
intermittent  in  appearance,  and  moderate  in  degree,  while  at 
others  it  is  stabbing  or  lancinating,  agonising,  and  more  or  less 
continuous.  In  48  per  cent,  of  our  cases  the  symptom  was 
described  as  '  severe  '  or  '  continuous,'  and  in  38  per  cent,  as 
'  occasional.' 

Situation. — The  part  of  the  abdomen  to  which  the  pain  is 
referred  varies  to  a  great  extent  according  to  the  situation  of  the 
growth.  In  pyloric  disease  the  epigastrium,  right  hypochon- 
drium,  or  even  the  umbilical  or  hypogastric  region,  may  be  the 
chief  seat  of  the  suffering,  according  as  the  pylorus  maintains 
its  usual  position  or  has  been  dislocated  by  traction  of  the 
enlarged  stomach.  When  the  body  of  the  organ  is  affected, 
pain  is  principally  experienced  in  the  epigastrium  or  left 
hypochondrium,  while  in  disease  of  the  cardia  it  is  often  felt  in 
the  left  side  of  the  chest,  in  the  throat,  or  behind  the  lower  end  of 
the  sternum.  Pain  in  the  back  is  most  often  encountered  with 
disease  of  the  posterior  wall,  associated  with  ulceration  of  the 
growth  and  adhesions  between  the  stomach  and  the  pancreas 
or  the  vertebral  column.  Moderate  pain,  such  as  arises  from 
flatulent  distension  of  the  viscus  in  the  early  stages  of  pyloric 
stenosis,  is  usually  referred  to  a  spot  in  the  centre  of  the  chest, 
beneath  the  left  mamma,  or  between  the  shoulders. 

Badiations. — At    the    climax  of   an  attack  the   pain   may 
become  diffused  over  a  large  area  of  the  body,  or  be  reflected 


SYMPTOMATOLOGY  111 

along  the  course  of  certain  nerves.  Thus  it  not  infre- 
quently extends  over  the  greater  part  of  the  abdomen  and  chest, 
or  radiates  to  the  back  and  upwards  between  the  shoulders. 
Occasionally  it  is  reflected  along  the  nerves  of  the  brachial, 
cervical,  or  lumbar  plexuses  ;  or,  should  the  disease  have 
involved  an  intercostal  nerve,  severe  neuralgia  may  be 
experienced  round  the  lower  part  of  the  chest  or  upper 
abdomen,  accompanied,  perhaps,  by  an  herpetic  eruption.  Pain 
in  the  right  shoulder  is  sometimes  associated  with  the  adhesion 
of  a  pyloric  growth  to  the  under  surface  of  the  liver ;  while 
invasion  of  the  diaphragm  is  often  accompanied  by  a  sense  of 
constriction  of  the  thorax,  with  difficulty  of  inspiration  and 
tenderness  along  the  course  of  the  phrenic  nerves  in  the  neck. 
Extension  of  the  growth  to  the  lumbar  and  sacral  glands  may 
give  rise  to  pain  in  the  nerves  of  the  lower  limbs  which 
simulates  sciatica,  and  extreme  irritability  of  the  bladder  or 
rectum  may  ensue  from  implication  of  the  pelvic  peritoneum. 
In  those  rare  cases  where  the  disease  destroys  the  spinal  column 
constant  localised  pain  in  the  back  may  be  followed  by  para- 
plegia. 

Time  of  Access. — At  an  early  stage  of  the  complaint  pain 
is  usually  experienced  after  meals,  and  in  this  respect  it 
resembles  that  of  simple  ulcer.  As  a  rule,  however,  it  is  less 
acute,  more  variable  in  appearance,  less  localised,  and  often 
relieved  by  the  eructation  of  gas.  As  the  disease  proceeds  it 
gradually  increases  in  severity,  and  becomes  more  continuous 
and  less  dependent  upon  digestion.  It  may  also  be  observed 
that,  unlike  the  pain  of  ulcer,  it  is  often  increased  rather  than 
relieved  by  a  milk  diet,  and  does  not  subside  entirely  after 
vomiting.  The  situation  of  the  growth  also  exerts  a  certain 
amount  of  influence  upon  its  development.  When  the  cardiac 
orifice  is  involved,  pain  is  usually  experienced  immediately  after 
swallowing,  and  is  excited  more  rapidly  by  solid  food  than  by 
liquids,  and  by  hot  or  cold  drinks  than  by  those  of  a  medium 
temperature.  Disease  of  the  body  of  the  organ  is  chiefly 
accompanied  by  pain  after  food,  which  in  its  situation  and 
time  of  access  closely  resembles  that  of  simple  ulcer.  The 
pain  that  accompanies  carcinoma  of  the  pylorus  varies  in  its 
appearance,  according  as  the  growth  has  ulcerated  or  has  given 
rise  to  obstruction  of  the  orifice.  In  the  former  case  there  is 
usually  an  exacerbation  within  half  an  hour  of  the  ingestion 


112  CANCEE  OF  THE   STOMACH 

of  food,  while  in  the  latter  a  sense  of  distension  and  abdominal 
discomfort  ensues  immediately  after  meals. 

Effect  of  Posture. — The  subjects  of  simple  gastric  ulcer 
often  find  relief  by  lying  upon  the  back  or  upon  one  side 
during  an  access  of  pain,  and  the  position  they  habitually 
assume  affords  a  general  clue  to  the  situation  of  the  ulcer.  In 
malignant  disease  of  the  stomach,  however,  a  recumbent  posture 
usually  aggravates  the  pain,  and  the  patient  repeatedly  turns 
from  side  to  side  in  his  efforts  to  obtain  relief,  or  walks  about 
the  room.  This  extreme  irritability  under  the  influence  of 
pain  is  very  characteristic,  and  its  existence  will  often  suggest 
the  possibility  of  malignant  disease  even  when  the  other  features 
of  the  complaint  seem  to  favour  a  diagnosis  of  simple  ulcer. 

Cause  and  Variations. — The  main  cause  of  the  pain  which 
accompanies  a  new  growth  in  the  stomach  is  undoubtedly  the 
progressive  infiltration  of  the  tissues  and  the  compression 
which  is  exerted  upon  the  gastric  nerves  by  extension  of  the 
disease  along  the  perineural  sheaths.  There  are,  however, 
several  other  conditions  which  tend  to  modify  both  the  severity 
of  the  symptom  and  its  time  of  access. 

(a)  Influence  of  Age. — It  is  often  stated  that  old  persons 
suffer  much  more  severely  than  those  of  middle  life.  To  test 
the  accuracy  of  this  view  we  have  arranged  in  the  following 
table  the  ages  of  our  various  patients  and  the  degrees  of  pain 
that  accompanied  their  complaint. 

Table  21. — The  Belation  of  Age  to  the  Severity  op  the  Pain 


Pain                                    Under  45  years 

45  to  60 

Over  60 

Absent  or  slight            .         .  :             10% 
Occasional            .         .         .                 48% 
Severe  or  continuous   .         .  1             42% 

15% 
33% 
52% 

14% 
36% 
50% 

It  will  be  observed  that  while  pain  in  one  form  or  another 
is  more  frequent  at  the  earlier  period  of  life,  continuous  or 
severe  suffering  is  slightly  more  common  after  forty-five  years 
than  among  younger  patients. 

(b)  Influence  of  Situation. — The  degree  of  pain  varies 
according  to  the  location  of  the  growth.  Brinton  asserted  that 
the  symptom  was  most  frequent  and  severe  when  the  orifices 
of  the  stomach  were  involved  by  the  disease,  and  this  statement 
has  usually  been  repeated   by  subsequent  writers.     Our  own 


SYMPTOMATOLOGY 


113 


experience,  however,  lias  always  led  us  to  regard  disease  of 
the  body  of  the  stomach  as  the  variety  which  is  pre-eminently 
painful,  and  this  appears  to  be  confirmed  by  an  analysis  of  our 
hospital  cases. 


Table  22 


Situation                                   No  pain 

Severe  pain 

43% 
66% 

42-5% 

Occasional  pain 

Carclia     .         .                                   24% 
Walls  and  curvatures       .                   3% 
Pylorus 15% 

33% 

31% 
42-5% 

An  examination  of  the  table  shows  that  nearly  one-fourth 
of  the  cases  where  the  cardiac  region  was  affected  were  devoid 
of  pain,  whereas  this  symptom  was  absent  in  only  3  per  cent. 
of  those  in  which  the  walls  and  curvatures  of  the  organ 
were  implicated.  It  is  also  obvious  that  severe  pain  was 
far  more  common  in  the  latter  than  in  the  former.  With 
regard  to  growths  of  the  pylorus,  pain  was  completely  absent 
in  15  per  cent.,  while  the  rest  suffered  equally  from  the 
occasional  and  severe  varieties.  It  is  interesting  to  note  that 
when  these  cases  were  further  classified  according  as  the 
pyloric  orifice  was  obstructed  or  not,  an  absence  of  pain  was 
found  to  be  entirely  confined  to  the  former  class.  The 
explanation  of  this  phenomenon  seems  to  be  that  when  a 
malignant  growth  infiltrates  the  pylorus,  without  causing  much 
obstruction,  the  mucous  membrane  is  usually  ulcerated  and  the 
disease  often  extends  into  the  body  of  the  stomach.  On  the 
other  hand,  a  contracting  scirrhus  which  produces  great 
stenosis  of  the  outlet  is  seldom  extensive,  and  is  usually  accom- 
panied by  excessive  vomiting,  which  in  itself  is  rarely  com- 
patible with  continued  pain. 

(c)  Influence  of  Ulceration. — Severe  pain  after  meals  is 
always  suggestive  of  ulceration.  We  have  therefore  compiled  the 
following  table,  in  order  to  show  the  relation  between  these  two 
conditions  in  carcinoma  of  the  different  regions  of  the  stomach. 

Table  23. — The  Belation  of  Pain  after  Food  to  Ulceration  of  the  Growth 


Situation 

Ulceration  present 

Pain  after  food 

Cardia 

Walls  and  curvatures 

43% 
57% 
48% 

33% 
37% 
46% 

114  CANCEE  OF  THE   STOMACH 

These  figures  are  interesting  from  two  points  of  view.  In 
the  first  place,  if  they  are  compared  with  those  shown  in 
Table  22  (p.  113),  it  will  be  seen  that  the  frequency  of  'pain 
after  food  '  and  of  '  occasional  pain  '  is  practically  identical  in 
growths  of  the  same  region  of  the  stomach.  In  other  words, 
that  whatever  designation  is  applied  to  this  form  of  pain,  it  is 
due  to  direct  irritation  of  the  ulcerated  surface  by  the  food  or  its 
chemical  products.  In  the  second  place,  it  is  apparent  that 
the  liability  to  the  symptom  varies  according  to  the  situation 
of  the  disease.  Thus,  while  it  exists  in  almost  every  case  of 
ulcerated  carcinoma  of  the  pylorus,  it  is  present  only  in  76  per 
cent,  of  the  cases  of  malignant  ulceration  of  the  cardia  and 
in  65  percent,  of  those  where  the  central  region  of  the  viscusis 
affected.  This  apparent  anomaly  may  be  easily  explained. 
As  long  as  the  pylorus  remains  unobstructed  the  gastric  con- 
tents find  a  ready  exit  into  the  duodenum  ;  but  if  the  orifice  is 
contracted,  both  the  food  itself  and  the  organic  acids  which 
arise  from  fermentation  tend  to  accumulate  in  the  stomach  and 
to  produce  direct  irritation  of  the  raw  surface.  It  is  also  pro- 
bable that  the  severe  and  continuous  form  of  pain  that  accom- 
panies disease  of  the  body  of  the  organ  frequently  masks  the 
less  intense  suffering  that  ensues  from  the  ingestion  of  food. 

(d)  Extent  of  the  Growth. — So  many  factors  are  concerned 
in  the  causation  of  the  pain  that  it  is  impossible  to  determine 
whether  the  histological  character  of  the  growth  exerts  any  de- 
cided influence  upon  the  severity  of  the  symptom.  As  it  is  often 
asserted,  however,  that  diffuse  infiltrations  are  more  painful  than 
localised  growths,  we  have  analysed  our  cases  upon  this  basis. 

Table  24. — Relation  of  Pain  to  the  Extent  of  the  Growth 


Pain 

Diffuse  infiltration 

Localised  growth 

Absent  or  slight 

Occasional          .... 

Constant              .... 

14% 
33% 
53% 

9% 

34% 
57% 

It  would  appear  that  as  a  rule  a  circumscribed  tumour  is 
rather  more  often  accompanied  by  pain  than  the  diffuse  variety, 
possibly  on  account  of  its  greater  tendency  to  deep  ulceration 
and  to  the  production  of  metastases. 

(e)     Secondary    Growths. — The    gradual   increase    of   pain 
which  often  marks  the  progress  of  the  disease  might  possibly 


SYMPTOMATOLOGY  115 

arise  from  implication  of  the  peritoneum  or  of  the  neighbouring 
viscera.  To  ascertain  the  truth  of  this  supposition  we  have 
analaysed  our  cases  in  the  following  way. 

Table  25. — Belation  of  Pain  to  Secondary  Growths  in  the  Abdomen 


Nature  of  pain  Growths  in  liver         Growths  in        :    Liver  and  peritoneum 

'  peritoneum  normal 


Absent  or  slight ...  7%  2%  14% 

Occasional  .         .         .         .  40%  19%  38% 

Constant     .         .         .         .  j  53%  79%  48% 


It  would  appear  that  wThile  metastases  in  either  tissue  increase 
the  tendency  to  pain,  the  symptom  is  most  severe  when  the 
peritoneum  is  involved  by  the  morbid  growth. 

Conclusions. — (1)  Some  degree  of  pain  is  present  in  about 
85  per  cent,  of  all  cases.  (2)  The  milder  forms  usually  arise 
from  flatulence,  while  the  more  severe  are  due  to  the  infiltra- 
tion and  destruction  of  the  gastric  tissues.  (3)  Pain  after  food 
is  a  prominent  symptom  in  38  per  cent.,  and  is  almost  invariably 
associated  with  ulceration  of  the  morbid  growth.  (4)  Severe 
or  constant  pain  occurs  in  48  per  cent,  of  all  cases.  If  it  arises 
at  an  early  stage  of  the  complaint,  the  walls  or  curvatures  are 
usually  affected,  but  as  a  late  phenomenon  it  is  often  due  to 
implication  of  the  peritoneum  or  to  metastatic  growths  in 
neighbouring  viscera.  (5)  Its  location  and  radiations  vary 
with  the  situation  and  extent  of  the  disease. 

(3)  Vomiting". — According  to  Brinton,  vomiting  occurs  in 
87-5  per  cent,  of  all  gastric  cancers.  Lebert  observed  it  in  80 
per  cent,  of  his  cases,  while  in  our  own  series  it  was  recorded  in  87 
per  cent.,  and  in  9  per  cent,  it  constituted  the  initial  symptom 
of  the  disease.  Like  pain,  it  varies  greatly  in  severity,  in  some 
instances  appearing  only  at  an  advanced  stage  of  the  complaint, 
while  in  others  it  either  occurs  at  intervals  or  is  so  frequent  as 
to  take  precedence  of  all  the  other  symptoms.  An  analysis  of 
our  154  cases  gives  the  following  results  :  no  vomiting  in  13 
per  cent.,  occasional  vomiting  in  7  per  cent.,  frequent  vomiting 
in  80  per  cent. 

(a)  Complete  absence  of  vomiting  is  so  very  exceptional 
that  the  term  '  no  vomiting  '  must  be  held  to  imply  that  the 
symptom  was  so  unimportant  that  it  failed  to  attract  the  atten- 
tion of  the  patient.     In  most  of  these  cases  the  disease  appears  in 

i  2 


116 


CANCEE   OP  THE   STOMACH 


the  form  of  a  localised  growth  upon  the  posterior  wall  or  curva- 
tures of  the  stomach,  though  occasionally  a  considerable  area 
may  be  involved,  provided  the  orifices  are  not  obstructed.  The 
stomach  shown  in  fig.  12,  p.  14,  was  taken  from  a  man  who 
vomited  only  twice  during  the  whole  course  of  his  illness.  It 
is  important  to  observe  that  in  all  these  cases  pain  is  usually 
excessive,  and  that  in  many  of  them  the  liver  becomes  affected 
with  secondary  growths  at  a  comparatively  early  period  of  the 
disease.  Absence  of  both  pain  and  vomiting  is  very  rare,  and 
was  noted  only  once  in  our  series  of  cases  (0*65  per  cent.). 

Latency  of  the  symptom  may  arise  from  several  causes.  In 
the  first  place,  it  is  well  known  that  the  normal  excitability  of 
the  vomiting  centre  in  the  medulla  oblongata  varies  consider- 
ably in  different  individuals,  some  being  affected  with  sickness 
from  the  most  trifling  causes,  while  in  others  the  induction  of 
vomiting  is  a  matter  of  the  greatest  difficulty.  Again,  frequent 
vomiting  rarely  coexists  with  severe  gastric  pain,  on  account 
of  the  restricted  diet  and  the  constant  use  of  opiates  which  the 
suffering  necessitates.  Finally,  the  profound  general  exhaustion 
which  accompanies  the  progress  of  the  malignant  disease 
gradually  depresses  the  nervous  system  and  diminishes  its  reflex 
functions. 


Table  26. — Showing  the  Eelative  Severity  of  the  Vomiting  in  Carcinoma 
of  different  Regions  of  the  Stomach 


Situation 

Vomiting  absent 

Occasional 

Frequent 

Walls  and  curvatures    .         .         . 
General  infiltration       .... 
Pylorus  (without  stricture)    . 
Pylorus  (with  stricture) 

24-5% 
11% 
17% 
3% 

23% 
5% 
3% 
3% 

52-5% 
84% 
80% 
94% 

(b)  Occasional  vomiting  is  characterised  by  attacks  of  emesis, 
which  recur  at  irregular  intervals  throughout  the  course  of  the 
disease.  As  a  rule  they  do  not  appear  until  the  third  or  fourth 
month,  but  occasionally  they  constitute  the  first  symptom. 
The  vomiting  may  occur  quite  suddenly,  or  it  may  be  preceded 
by  an  increase  of  pain,  flatulence,  distension,  or  nausea.  In  the 
former  case  it  often  takes  place  in  the  early  morning  or  before 
a  meal,  and  results  in  the  rejection  of  several  ounces  of  viscid 
mucus ;  while  in  the  latter  it  ensues  after  rr  eals,  and  causes 


SYMPTOMATOLOGY  117 

the  evacuation  of  a  large  quantity  of  undigested  and  ferment- 
ing food.  In  both  instances  the  ejecta  usually  contain  lactic 
acid,  but  are  devoid  of  free  hydrochloric  acid.  The  fre- 
quency of  the  symptom  varies  in  different  cases,  in  some 
occurring  only  every  two  or  three  weeks,  while  in  others  an 
attack  is  experienced  every  six  or  seven  days.  Its  exciting 
cause  is  equally  variable,  an  unduly  large  meal,  indulgence  in 
beer  or  wine,  over-excitement,  or  exposure  to  cold  or  fatigue, 
being  liable  in  many  patients  to  produce  sickness.  In  almost 
every  instance  pain,  either  constant  or  occasional,  is  a  marked 
symptom,  and  as  a  rule  the  vomiting  affords  a  welcome  though 
temporary  relief.  A  glance  at  Table  26  shows  that  occasional 
vomiting  is  most  frequent  when  the  morbid  growth  affects  the 
walls  or  curvatures  of  the  stomach  without  implication  of  the 
orifices,  and  it  may  therefore  be  attributed  partly  to  local  irrita- 
tion of  the  gastric  nerves,  and  partly  to  the  chronic  gastritis 
which  always  accompanies  the  disease. 

(c)  Frequent  vomiting  occurs  in  the  great  majority  of  cases 
at  a  late  stage  of  the  disease,  and  is  present  in  some  throughout 
its  entire  course.  Its  time  of  advent  and  its  severity  depend 
chiefly  upon  the  situation  and  extent  of  the  growth  and  the 
existence  of  ulceration. 

The  most  characteristic  variety  is  met  with  m  stenosis  of 
the  pyloric  orifice.  In  this  condition  severe  pain  is  rarely 
experienced,  but  flatulence,  distension,  and  acidity  are  always 
prominent  symptoms.  When  the  disease  commences  at  the 
pylorus,  and  implicates  the  valve,  vomiting  may  be  present 
from  the  first ;  but  when  the  growth  induces  rigidity  of  the 
tissues,  or  merely  involves  the  outlet  by  a  process  of  ex- 
tension, five  months  or  more  may  elapse  before  the  sickness 
becomes  frequent.  At  first  the  attacks  are  only  occasional, 
and  chiefly  occur  during  the  night  or  after  an  unduly  large 
meal ;  but  with  the  progress  of  the  complaint  they  become 
more  and  more  frequent,  until  vomiting  takes  place  every  few 
days.  At  this  period  the  sequence  of  events  is  somewhat  as 
follows :  loss  of  appetite  and  the  discomfort  that  ensues  after 
meals  have  induced  the  patient  to  restrict  himself  to  liquid  or 
semi-solid  food,  but  even  under  these  circumstances  he  suffers 
every  second  or  third  day  from  abdominal  distension,  acidity, 
and  nausea.  In  order  to  procure  relief  he  will  often  induce 
vomiting  by  inserting  his  finger  down  the  throat ;  but  very 


118  CANCER  OP  THE   STOMACH 

soon  the  symptoms  culminate  spontaneously  in  emesis,  whereby 
the  stomach  rids  itself  of  a  large  quantity  of  sour  fermenting 
material.  Comparative  comfort  is  enjoyed  for  the  next  twenty- 
four  hours,  after  which  time  the  symptoms  of  maldigestion 
recur,  to  terminate  once  more  in  vomiting.  Although  intense 
nausea  may  be  experienced,  very  little  effort  is  required  to 
evacuate  the  stomach,  the  process  being  one  of  gentle  regurgi- 
tation, which  is  markedly  favoured  by  a  recumbent  posture. 
Gradually  the  intervals  of  relief  become  shorter,  until  hardly  a 
day  passes  without  one  or  more  attacks  of  emesis.  This  con- 
dition may  persist  until  the  end,  or  it  may  subside  a  few  days 
before  death  owing  to  profound  exhaustion  and  inability  to 
take  nourishment. 

Subsidence  of  the  vomiting  at  an  earlier  period  may  ensue 
either  from  sloughing  of  the  growth  which  had  caused  the 
obstruction,  or  from  the  establishment  of  a  fistulous  com- 
munication with  the  intestine.  The  former  is  often  accom- 
panied by  severe  epigastric  pain  and  diarrhoea,  and  sometimes  by 
melsena  or  hsematemesis,  after  which  the  patient  experiences 
much  relief.  Should  the  orifice  remain  patent,  this  ameliora- 
tion may  continue  for  some  time ;  but  if  the  exuberant  growth 
recurs  the  former  symptoms  gradually  reassert  themselves. 
The  formation  of  a  fistula  is  a  late  event  in  the  disease,  and 
the  relief  it  affords  is  usually  evanescent. 

The  ejecta  in  the  cases  of  pyloric  stenosis  are  very  charac- 
teristic. The  quantity  varies  from  three-quarters  of  a  pint  to 
two  quarts  or  more,  and  the  semi-liquid  material  is  dark 
brown  in  colour  and  possesses  a  sour,  sickly,  pungent,  rancid, 
or  even  an  offensive  smell.  When  filtered  the  fluid  is  found  to 
be  acid  in  reaction,  owing  to  the  presence  of  lactic  acid,  but  free 
hydrochloric  acid  is  usually  absent.  Occasionally  acetic  or 
butyric  acid  maybe  detected  in  it.  The  residue  upon  the  filter- 
paper  consists  of  masses  of  undigested  food  and  a  large  quantity 
of  mucus.  One  of  the  most  important  features  of  the  vomit  is 
the  appearance  in  it  of  some  article  of  diet  which  had  been 
swallowed  at  a  distant  date,  such  as  date  or  grape  skins,  beans, 
peas,  currants,  corn,  grape-stones,  or  orange-pips.  In  one  of 
our  cases  some  french  beans  were  vomited  in  an  unaltered 
state  nearly  four  weeks  after  they  had  been  eaten.  Micro- 
scopical examination  of  the  sediment  reveals  various  kinds  of 
debris,   sarcinse,   torula?,   micro-organisms,  red  corpuscles,  and 


SYMPTOMATOLOGY  119 

occasionally  minute  particles  of  the  morbid  growth.  Offensive 
vomit  usually  denotes  putrefaction  of  the  proteid  constituents 
of  the  food,  but  in  rare  cases  it  arises  from  sloughing  of  the 
growth.  A  faecal  odour  indicates  intestinal  obstruction  or 
gastro-colic  fistula. 

The  periodic  vomiting  of  pyloric  stenosis  is  liable  to  be 
superseded  from  time  to  time  by  urgent  and  continuous  sick- 
ness, which  persists  for  several  days  and  entirely  precludes  the 
administration  of  food  by  the  mouth.  This  variety  is  usually 
due  to  an  attack  of  subacute  gastritis,  caused  by  retention  and 
decomposition  of  the  food  ;  but  occasionally  it  arises  from  peri- 
tonitis at  the  base  of  the  growth,  from  kinking  or  twisting  of 
the  duodenum,  or  from  secondary  obstruction  of  the  colom  In 
rare  instances  the  impaction  of  undigested  material  or  a  foreign 
body  in  the  contracted  pylorus  leads  to  a  rapidly  fatal  ter- 
mination. 

Case  IV.  A  man,  forty-nine  years  of  age,  was  admitted  into  the 
London  Hospital  for  incessant  vomiting  of  three  days'  duration.  It 
appeared  from  his  history  that  for  several  months  he  had  suffered 
from  indigestion  and  loss  of  appetite,  and  latterly  had  vomited  every 
third  or  fourth  day.  He  had  also  lost  much  flesh.  Three  days  pre- 
viously the  sickness  had  become  incessant,  and  was  accompanied  by 
a  dull  pain  at  the  epigastrium.  On  examination  the  man  appeared 
profoundly  ill,  the  eyes  being  sunken,  the  extremities  cold,  and  the 
pulse  hardly  perceptible.  About  every  ten  minutes  he  was  seized  with 
urgent  retching,  and  rejected  about  an  ounce  of  an  opalescent,  alkaline, 
mucoid  fluid.  The  stomach  was  dilated,  and  an  ill-defined  tumour 
could  be  felt  in  the  region  of  the  pylorus.  Death  occurred  from 
syncope  within  twelve  hours  of  admission.  The  necropsy  showed 
cancerous  infiltration  of  the  pylorus,  in  the  contracted  orifice  of  which 
a  damson-stone  was  firmly  impacted. 

Ulceration  of  the  growth  may  give  rise  to  a  species  of 
vomiting  similar  to  that  which  occurs  in  simple  ulcer.  In 
such  cases  the  lesion  is  usually  situated  near  the  pylorus, 
though  it  need  not  necessarily  obstruct  the  orifice.  Epigastric 
pain  is  either  excited  or  increased  by  the  ingestion  of  food, 
and  is  only  partially  relieved  by  the  evacuation  of  the  gastric 
contents.  This  form  of  frequent  vomiting  rarely  persists  more 
than  a  few  months.  As  a  rule,  either  it  merges  into  that  which 
characterises  pyloric  stenosis,  or  the  attacks  become  less  fre- 
quent as  the  disease   progresses  and   metastases  in   the  liver 


120  CANCEE  OF  THE   STOMACH 

present  themselves.  The  ejecta  consist  entirely  of  undigested 
food  mixed  with  mucus,  and  perhaps  with  altered  blood.  Free 
hydrochloric  acid  is  usually  absent,  but  lactic  acid  may  be 
present  in  excess. 

Diffuse  infiltrations  of  the  stomach  also  produce  frequent 
vomiting  by  contracting  the  organ  and  destroying  its  muscular 
tissue.  In  such  the  patient  feels  that  the  capacity  of  his 
stomach  is  limited,  and  any  attempt  to  overtax  it  is  followed 
by  regurgitation  of  the  surplus  quantity.  Should  the  pylorus 
be  stenosed,  periodic  vomiting  may  also  occur,  the  only 
difference  from  the  usual  type  being  that  the  vomit  is  com- 
paratively small  in  amount.  If  ulceration  exists,  pain  as  well  as 
sickness  may  follow  the  administration  of  food. 

(4)  Haemorrhage  (Hsematemesis  and  Melaena). — It  is  pro- 
bable that  some  degree  of  haemorrhage  occurs  in  every  case 
of  cancer  of  the  stomach,  and  that  in  many  it  is  practically 
continuous  ;  but  since  its  clinical  recognition  depends  upon  its 
severity  and  the  coexistence  of  vomiting,  its  frequency  has 
been  variously  estimated  by  different  writers.  Thus,  Brinton 
noted  haematemesis  in  42  per  cent,  of  his  cases,  Lebert  in  12-5 
per  cent.,  Boas  in  36  per  cent.,  Osier  and  McCrae  in  24  per 
cent.,  and  Bosenheim  in  50  per  cent.  ;  while  in  our  own  series 
it  was  present  in  34  per  cent.  The  clinical  aspect  of  gastric 
haemorrhage  varies  according  to  the  quantity  of  blood  which  is 
lost,  and  may  be  appropriately  described  under  the  terms 
'  slight,'  '  moderate  '  and  '  severe.' 

(a)  Slight  liamorrliage. — -In  this  category  are  included  those 
small  but  frequent  losses  of  blood  which  ensue  from  superficial 
ulceration  of  the  growth  or  from  engorgement  of  its  vessels  and 
of  those  of  the  surrounding  mucous  membrane.  The  Weeding 
may  occur  spontaneously  or  it  may  be  excited  by  the  inges- 
tion of  food  ;  while  occasionally  the  use  of  alcohol,  severe 
retching,  straining  at  stool,  or  pressure  upon  the  epigastrium 
appears  to  be  the  determinant  factor  in  its  production.  The 
liability  to  this  form  of  haemorrhage  is  also  increased  by  any 
condition  which  increases  the  pressure  of  the  blood  in  the  gastric 
vessels  or  which  materially  alters  the  composition  of  that  fluid. 
Thus,  frequent  venous  oozing  is  very  common  when  the  disease 
is  complicated  by  a  valvular  affection  of  the  heart,  cirrhosis  of 
the  liver,  interstitial  nephritis,  enlargement  of  the  spleen,  or 
leuchaemia.     In  some  women  it  is  especially  apt  to  occur  just 


SYMPTOMATOLOGY  121 

before  the  catamenial  period.  The  amount  of  blood  effused  on 
each  occasion  varies  from  a  drachm  to  three  or  four  ounces.  If 
vomiting  occurs  the  ejecta  present  a  brown  tinge  and  gritty 
appearance  (coffee-grounds),  owing  to  the  conversion  of  the 
albuminous  constituents  of  the  blood  into  globulin  and  the 
reduction  of  the  haemoglobin  to  insoluble  hsematin.  Several 
substances  besides  blood  impart  a  brownish  tint  to  the  vomit, 
as,  for  example,  red  wines,  coffee,  and  the  various  preparations 
of  iron  ;  while  a  similar  colouration  of  the  stools  may  be  pro- 
duced by  the  administration  of  bismuth  and  calomel.  It  is 
therefore  important  that  in  every  case  the  vomit  should  be 
carefully  examined  for  brownish-black  masses  or  flakes. 
Under  the  microscope  these  minute  particles  are  seen  to 
be  composed  of  granules  of  pigment  mixed  with  shrunken 
red  corpuscles  ;  and  if  there  is  any  doubt  as  to  the  nature 
of  the  colouring  matter,  resort  should  be  had  to  the 
following  process,  devised  by  Korczinski  and  Jaworski.  A 
small  quantity  of  the  suspected  material  is  mixed  in  a  porcelain 
dish  with  a  few  grains  of  chlorate  of  potassium  and  a  drop  of 
hydrochloric  acid,  and  gently  evaporated  to  dryness.  If  any 
altered  blood  is  present,  the  addition  of  a  dilute  solution  of 
ferrocyanide  of  potassium  to  the  residue  produces  an  intense 
blue  colour.  The  filtered  vomit  may  also  be  examined  for 
blood  by  Weber's  modification  of  the  guaiacum  test.  The 
filtrate  is  mixed  with  one-third  of  its  bulk  of  glacial  acetic 
acid,  and  after  being  well  shaken  is  allowed  to  stand  for  a 
short  time.  Ten  cubic  centimeters  of  the  fluid  are  then 
measured  off  into  a  test-tube,  and  to  them  are  added  ten  drops 
of  a  freshly  prepared  tincture  of  guaiacum  and  twenty-five  drops 
of  turpentine.  If  any  blood  is  present  the  mixture  acquires  a 
violet-blue  colour,  but  under  other  circumstances  it  appears 
reddish  brown. 

Frequent  slight  oozing  of  blood,  although  it  may  not  be 
accompanied  by  immediate  symptoms,  always  exercises  a 
deleterious  influence  upon  the  general  health.  In  addition 
to  progressive  debility,  the  skin  and  mucous  membranes 
become  manifestly  anseinic,  and  shortness  of  breath,  giddi- 
ness, or  faintness  is  experienced  on  exertion.  The  appetite 
disappears,  thirst  is  often  excessive,  and  sleep  is  disturbed 
by  attacks  of  palpitation  and  flatulence.  If  vomiting  is 
absent  and  pain    an  unimportant  symptom,  the  hoernorrhage 


122  CANOBE  OF  THE   STOMACH 

almost  invariably  escapes   detection,  and  the   case  is  usually 
regarded  as  one    of   pernicious    anaemia.     When,    however,    a 
soft  tube  is  inserted  into  the  stomach  during  the  period  of 
digestion,  it  is  by  no  means  unusual  to  find  that  the  gastric 
contents  are  largely  mixed  with  altered  blood.    This  unexpected 
discovery  was  made  in  several  cases  which  came  under  our  notice 
for  anaemia  and  indigestion,  and  in  every  instance  where  the 
bleeding   appeared   to    be   continuous  a  necropsy  showed  the 
existence  of  an  ulcerated  growth,  usually  of  the  scirrhous  type. 
In  several  of  these  it  was   also  observed  that  the  degree  of 
anaemia  varied  with  the  severity  of  the  haemorrhage,  and  that 
when  the  latter  was  controlled  by  treatment  the  anaemia  became 
less  intense.     Boas  has  lately  called  attention  to  these  facts, 
and  states  that  he  has  observed  twenty  cases  of  cancer  of  the 
stomach  in  which  constant  haemorrhage  was  detected  by  means 
of  the  tube.     It  must,  therefore,  be  admitted   that    frequent 
oozing  of  blood  may  take  place  without  the  objective  symptom 
of  haematemesis,  and  that  its  existence  can  only  be  determined 
by  a  methodical  examination  of  the  contents  of  the  stomach. 
Furthermore,  there  is  reason  to  believe  that  this  loss  of  blood 
is  one  of  the  chief  causes  of  the  so-called  cachexia  of  gastric 
cancer. 

(b)  Moderate  Hemorrhage. — This  variety  closely  resembles 
that  which  ensues  from  simple  ulcer,  and  is  generally  evidenced 
by  the  vomiting  of  six  to  eighteen  ounces  or  more  of  blood. 
This  copious  bleeding  is  usually  brought  about  by  the  destruction 
of  a  medium-sized  vessel  in  the  submucous  or  subserous  tissue 
of  the  stomach,  but  occasionally  it  arises  from  sloughing  of  a 
vascular  growth,  or  from  ulceration  of  an  artery  of  some 
neighbouring  viscus.  It  is  most  frequent  when  the  orifices  or 
the  lesser  curvature  are  the  seat  of  disease,  and  is  hardly 
ever  encountered  in  growths  which  produce  extreme  stenosis 
of  the  pylorus.  Brinton  estimated  that  this  form  of  haemate- 
mesis occurred  in  7  per  cent,  of  all  cases  of  gastric  cancer,  but 
our  own  statistics  indicate  a  frequency  of  10*8  per  cent.  The 
colour  of  the  vomit  varies  according  to  the  rapidity  of  the 
effusion  and  the  length  of  time  the  blood  has  remained  in  the 
stomach,  sudden  haemorrhage  and  immediate  vomiting  being 
evidenced  by  the  rejection  of  bright  clotted  blood,  while  a 
more  tardy  expulsion  renders  it  darker  in  colour  and  more 
fluid  in  consistence.     In  many  cases  the  haematemesis  occurs 


SYMPTOMATOLOGY  123 

without  premonition,  but  in  others  it  is  preceded  by  a  sense 
of  heat  or  fulness  at  the  epigastrium,  palpitation,  a  peculiar 
taste  in  the  mouth,  nausea,  faintness,  dyspnoea,  or  even  con- 
vulsions. 

The  symptoms  vary  according  to  the  severity  of  the 
haemorrhage  and  the  condition  of  the  patient.  If  the  loss  of 
blood  is  strictly  moderate  in  amount  and  the  general  nutrition 
good,  the  patient  exhibits  the  usual  signs  of  loss  of  blood.  The 
face  becomes  pallid,  the  skin  cold  and  clammy,  and  there  is 
great  restlessness  and  a  desire  for  air.  The  pulse  increases  in 
frequency  but  diminishes  in  volume,  and  there  is  usually  com- 
plaint of  weakness,  faintness,  or  vertigo.  Occasionally  palpita- 
tion, dimness  of  vision,  noises  in  the  ears,  or  a  sense  of  empti- 
ness and  sinking  at  the  epigastrium,  are  notable  features  of  the 
attack.  Dryness  of  the  mouth  and  thirst  are  invariably 
present.  During  the  continuance  of  the  haemorrhage  the 
pulse  is  quick,  small,  and  compressible,  and  in  bad  cases  may 
cease  to  be  felt  at  the  wrist,  while  the  temperature  of  the  body 
is  markedly  depressed. 

As  soon  as  the  bleeding  has  ceased  a  certain  amount  of 
reaction  sets  in,  and  the  pulse  increases  in  volume,  though  it 
still  continues  to  exhibit  the  compressible  and  jerky  character 
of  an  incompletely  filled  artery.  The  temperature  also  recovers 
itself,  and  may  even  rise  one  or  two  degrees  above  the  normal, 
but  the  febrile  reaction  is  much  less  noticeable  than  in  cases  of 
simple  ulceration.  During  this  period  the  cheeks  become 
slightly  flushed,  the  eyes  sunken  and  surrounded  by  dark  lines, 
the  lips  dry  and  cracked,  and  sordes  may  collect  about  the 
teeth.  Owing  in  great  measure  to  the  prohibition  of  solid  food, 
the  tongue  is  dry  and  coated  with  a  grey  or  brown  fur,  while 
the  palate  and  throat  are  apt  to  be  attacked  by  thrush.  Thirst 
is  always  a  prominent  symptom,  but  all  desire  for  food  is  absent. 
Among  the  minor  symptoms,  throbbing  in  the  head,  noises  in 
the  ears,  palpitation,  insomnia,  and  uncontrollable  restlessness 
are  the  chief  subjects  of  complaint. 

As  a  rule  the  gastric  symptoms  remain  temporarily  in  abey- 
ance, and  even  when  severe  pain  has  preceded  the  hseniatemesis 
it  almost  invariably  subsides  for  the  time.  The  bowels  are  con- 
fined, and  it  may  not  be  until  they  have  been  opened  once  or 
twice  that  a  black  appearance  of  the  stool  proves  that  some  blood 
has  found  its  way  into  the  intestines.     In  other  cases  the  first 


124  CANCEE  OF  THE   STOMACH 

evacuation  is  found  to  contain  blood,  and  several  liquid  tarry 
motions  are  passed  in  rapid  succession.  The  amount  voided 
in  this  manner  is  usually  in  inverse  proportion  to  the  quantity 
vomited. 

When  the  heemorrhage  occurs  at  a  late  stage  of  the  disease, 
the  symptoms  are  often  modified  by  the  low  vitality  of  the 
patient.  Thus,  in  many  instances  vomiting  is  absent,  and  an 
attack  of  syncope  or  collapse,  followed  by  intense  prostration, 
constitutes  the  only  indication  of  the  loss  of  blood.  In  others 
the  first  attack  is  followed  by  continuous  vomiting  of  coffee- 
ground  material,  or  small  quantities  of  bright  blood  continue 
to  be  rejected  at  intervals.  Not  infrequently  the  bleeding 
is  followed  within  a  few  days  by  intense  pain  after  food,  which 
prevents  the  administration  of  nourishment  and  leads  to  rapid 
loss  of  strength.  Lastly,  the  haemorrhage  may  induce  a  semi- 
comatose condition,  from  which  the  patient  never  rallies,  or  it 
is  followed  by  pneumonia,  profuse  diarrhoea,  or  suppuration  of 
the  parotid  gland,  which  rapidly  destroys  life.  It  is  very  rare 
for  moderate  hsematemesis  to  recur  at  distant  intervals. 

(c)  Excessive  Hemorrhage  (V hemorrhagic  foudroyante). — 
Haemorrhage  of  such  severity  as  to  prove  immediately  fatal  is 
very  rare.  Brinton  estimated  its  frequency  at  1  per  cent.,  and 
this  tallies  with  our  own  figures  (075  per  cent.)  and  those  of 
other  writers.  In  most  cases  it  ensues  from  rupture  of  the 
coronary,  splenic,  or  gastro-epiploic  artery,  but  occasionally 
the  aorta,  vena  cava,  or  hepatic  vessels  are  affected.  Soft 
growths  of  the  lesser  curvature  and  of  the  cardiac  end,  which 
have  undergone  rapid  sloughing  with  destruction  of  the  gastric 
tissues,  are  the  most  common  cause  of  the  accident.  As  a  rule 
the  patient  is  suddenly  seized  with  vertigo,  becomes  blanched, 
and  loses  consciousness.  Sometimes  convulsions  occur.  Not 
infrequently  the  shock  is  so  great  as  to  paralyse  the  nervous 
centres  and  to  prevent  vomiting.  In  such  the  stomach  and 
intestines  are  Tound  to  be  filled  with  blood  after  death,  or  a 
fluctuating  tumour  in  the  epigastrium,  due  to  distension  of  the 
stomach  with  clot,  may  be  detected  before  life  becomes  extinct. 
In  other  cases  profuse  haematemesis  is  followed  by  immediate 
and  fatal  collapse. 

(5)  Disorders  of  Digestion.  -  In  addition  to  pain  and  vomiting, 
most  of  the  subjects  of  gastric  carcinoma  also  suffer  from  minor 
symptoms  arising  from  derangement  of  the  digestive  organs. 


SYMPTOMATOLOGY  125 

The  most  important  of  these  are  anorexia,  dysphagia,  flatulence, 
nausea,  pyrosis,  and  constipation. 

Anorexia. — Loss  of  appetite  is  an  important  symptom  of 
gastric  cancer.  Brinton  observed  it  in  85  per  cent,  and  Lebert 
in  80  per  cent,  of  their  respective  cases.  In  our  own  series 
pronounced  anorexia  existed  in  82  per  cent.,  in  11  per  cent,  the 
appetite  was  normal,  and  in  two  instances  (1-5  per  cent.)  it  was 
apparently  increased.  As  a  rule  the  distaste  to  food  shows 
itself  after  the  dyspepsia  has  persisted  for  some  time  ;  but  in  34 
per  cent,  of  our  cases  it  constituted  one  of  the  first  symptoms 
of  the  complaint  and  persisted  throughout  its  entire  course. 
In  the  majority  of  these  the  growth  was  found  after  death  to 
occupy  the  cardiac  or  central  region  of  the  stomach,  and 
usually  belonged  to  the  medullary  or  cylindrical-celled  type. 
When  once  it  has  appeared  the  anorexia  usually  increases  in 
severity  until  it  becomes  absolute  ;  but  occasionally  it  varies  in 
degree  from  time  to  time,  and  may  even  disappear  for  a  few 
days.  At  first  it  may  only  be  meat  or  some  special  article  of 
diet,  such  as  fat,  butter,  or  eggs,  which  proves  distasteful,  but 
as  the  disease  progresses,  and  especially  if  it  is  accompanied  by 
frequent  vomiting,  it  becomes  more  and  more  difficult  to 
persuade  the  patient  to  take  any  kind  of  nourishment.  It  may 
be  noticed  that  the  desire  for  tobacco  and  snuff  is  usually 
abolished,  and  that  in  rare  instances  a  special  though  tempo- 
rary craving  exists  for  fruit,  herrings,  or  jam.  The  way  in 
which  the  anorexia  shows  itself  varies  in  different  cases.  In 
the  majority  there  is  simply  no  wish  for  food  ;  in  others  constant 
nausea  or  difficulty  of  deglutition  seems  responsible  for  the  loss 
of  appetite,  while  occasionally  the  very  sight  of  food  is  repug- 
nant. The  frequency  of  the  latter  phenomenon,  however,  has 
been  much  exaggerated,  although  when  it  exists  it  constitutes  a 
very  important  and  striking  symptom.  Thus,  a  lady  who  came 
under  our  care  stated  that  the  first  indication  of  illness  consisted 
in  such  extreme  aversion  to  the  sight  of  meat  that  she  was  unable 
to  pass  a  butcher's  shop  ;  and  in  another  case  we  were  assured 
by  a  gentleman  that  although  he  often  felt  inclined  for  food,  the 
appearance  of  a  joint  upon  the  table  at  once  excited  nausea  and 
sometimes  made  him  vomit. 

Dysphagia. — Difficulty  of  swallowing  is  by  no  means  infre- 
quent during  the  ■  later  stages  of  the  disease.  In  many  cases 
where  the  anorexia  is  extreme  the  patient  ascribes  his  dislike 


126  CANCEE  OF  THE   STOMACH 

to  food  to  an  inability  to  swallow,  and  complains  either  that  a 
special  effort  of  deglutition  is  required  to  dispose  of  each 
mouthful,  or  that  the  ingesta  become  arrested  in  the  oeso- 
phagus. The  former  condition  is  purely  subjective  in  character, 
and  is  usually  associated  with  some  disturbance  of  taste  or  an 
alteration  in  the  salivary  secretion,  while  the  latter  frequently 
arises  from  flatulence,  and  is  relieved  by  the  eructation  of  gas. 
True  dysphagia  accompanies  most  malignant  growths  which 
involve  the  cardiac  orifice  or  which  extend  into  the  oesophagus, 
and  in  such  cases  it  constitutes  the  principal  symptom.  Occa- 
sionally, however,  it  arises  from  reflex  spasm  of  the  pharynx  or 
oesophagus.  Thus  Ebstein  and  Eichhorst  have  recorded  cases 
in  which  tetany  of  the  constrictor  muscles  of  the  pharynx  was 
associated  with  carcinoma  of  the  pylorus,  and  Poncet,  Ewald, 
and  Osgood  have  related  others  where  the  spasm  affected  the 
lower  segment  of  the  oesophagus.  Two  cases  of  this  description 
have  come  under  our  own  notice.  In  the  first  the  difficulty  of 
swallowing  was  so  great  that  the  patient  had  to  restrict  himself 
to  liquids,  and  even  these  often  provoked  choking  and  regur- 
gitation. After  death  the  pyloric  third  of  the  stomach  was 
found  to  be  infiltrated  with  spheroidal-celled  carcinoma,  but  no 
organic  obstruction  existed  to  the  passage  of  food  into  the  viscus. 
The  other  case  was  remarkable  from  the  fact  that  no  stricture, 
either  functional  or  organic,  could  be  detected  during  life,  so 
that  the  dysphagia  was  probably  due  to  paresis  rather  than 
to  spasm  of  the  lower  end  of  the  oesophagus. 

Case  V.  A  man  aged  forty-eight  became  gradually  affected  with 
difficulty  of  swallowing,  which  in  a  few  weeks  prevented  him  from 
taking  any  solid  food.  Mouthfuls  of  milk  and  other  liquids  were 
easily  disposed  of,  but  if  drunk  hastily  or  in  bulk  the  fluids  gave  rise  to 
oppression  at  the  chest,  and  were  partially  regurgitated.  The  insuffi- 
cient nutrition  produced  rapid  loss  of  flesh,  and  within  a  few  months 
extreme  debility  necessitated  his  confinement  to  bed.  The  appetite 
was  bad,  and  hiccough  and  gaseous  eructations  were  a  constant 
source  of  annoyance.  Hsematemesis  was  absent,  and  there  was  no 
complaint  of  pain. 

On  examination  the  stomach  was  found  to  be  normal  in  size,  and 
no  tumour  or  localised  tenderness  could  be  detected  in  the  abdomen. 
There  were  no  signs  of  aneurysm  or  other  thoracic  tumour.  A  full- 
sized  tube  was  passed  without  difficulty  into  the  stomach,  and 
a  pint  of  milk  introduced  by  it  was  retained  without  difficulty. 
Notwithstanding  the  absence  of  a  stricture,  the  patient  continued 


SYMPTOMATOLOGY  127 

unable  to  swallow,  and  forcible  feeding  (garage)  was  instituted. 
For  two  or  tbree  weeks  tbis  proved  very  successful,  and  be  rapidly 
put  on  weigbt,  but  subsequently  discomfort  ensued  after  eacb  meal, 
and  occasionally  vomiting  occurred.  Tbe  stomach  was  now  found  to 
be  dilated,  and  a  sense  of  resistance  was  detected  in  the  region  of 
the  pylorus.  Tbe  food  regurgitated  after  tbe  tube  was  withdrawn, 
emaciation  set  in,  and  death  ultimately  occurred  from  exhaustion  about 
five  months  after  the  onset  of  the  dysphagia.  At  the  necropsy  the 
stomach  was  found  to  be  moderately  dilated,  and  the  pylorus  affected 
by  a  cancerous  infiltration,  which  had  produced  slight  stenosis.  The 
cardiac  orifice  was  patulous,  but  showed  no  sign  of  disease.  The 
oesophagus  was  normal. 

Nausea  is  present  in  68  per  cent,  of  all  cases,  and  is  usually 
experienced  after  meals  or  immediately  prior  to  an  attack  of 
vomiting.  A  constant  feeling  of  sickness  constituted  one  of  the 
earliest  symptoms  of  the  disease  in  27  per  cent,  of  our  cases, 
and  was  usually  accompanied  by  anorexia  and  loss  of  flesh,  and 
occasionally  by  giddiness  and  retching  in  the  early  morning.  It 
was  most  frequent  and  severe  when  the  cardiac  region  was  the 
seat  of  the  growth,  or  where  the  pylorus  was  involved  without 
the  production  of  stenosis.  The  marked  distaste  to  tobacco  and 
fats  often  causes  the  nausea  to  be  mistaken  for  '  biliousness.' 

Flatulence. — This  occurs  in  almost  every  case,  and  is  re- 
sponsible for  many  of  the  symptoms  of  dyspepsia.  It  is  a 
constant  phenomenon  in  stenosis  of  the  pylorus,  but  compara- 
tively infrequent  when  the  cardiac  orifice  is  obstructed.  The 
special  symptoms  to  which  it  gives  rise  vary  greatly  in  severity. 
In  some  cases  the  patient  merely  experiences  a  certain  amount 
of  fulness  and  discomfort  after  meals,  which  are  relieved  by 
eructation,  while  in  others  painful  distension  of  the  abdomen 
and  frequent  belchings  of  gas  persist  for  hours.  Although  it  is 
usually  increased  by  food,  it  is  also  troublesome  in  the  intervals 
of  digestion,  and  is  particularly  distressing  during  the  night. 
Sometimes  a  sense  of  thoracic  constriction  amounting  to  severe 
pain  ensues  upon  the  slightest  exertion,  while  at  other  times  the 
upward  displacement  of  the  heart  induces  violent  palpitation, 
throbbing  in  the  head,  or  vertigo.  Occasionally  syncope  or  pain 
like  that  of  angina  pectoris  occurs,  or  asthmatic  attacks  supervene 
after  meals,  accompanied  by  extreme  breathlessness  and  cyanosis. 
Hot  flushes,  with  headache,  confusion  of  thought,  somnolence 
and  hiccough,  also  constitute  a  frequent  source  of  complaint. 

Under    normal    circumstances    the    gaseous    contents    of 


128  CANCEE  OF  THE   STOMACH 

the  stomach  consist  of  air  which  has  heen  swallowed 
and  a  variable  quantity  of  carbon  dioxide,  derived  from  the 
blood  or  from  food-fermentation.  The  chyme  itself,  when 
removed  from  the  stomach,  exhibits  very  slight  gas  formation 
for  several  days,  owing  to  the  presence  of  hydrochloric  acid, 
which  controls  the  natural  tendency  to  putrefaction.  When, 
however,  obstruction  of  the  pylorus  or  inefficient  peristalsis 
has  delayed  the  transmission  of  food  into  the  bowel,  fermen- 
tation invariably  occurs,  and  leads  to  the  production  of  a 
considerable  quantity  of  gas.  This  process  can  readily  be 
studied  and  its  activity  estimated  by  filling  a  test-tube  of 
medium  size  with  the  semi-digested  food  withdrawn  by  a  tube, 
and  inverting  it  over  a  small  cup  or  glass  beaker  partially  filled 
with  the  same  material.  If  any  gas  is  evolved  it  will  collect  at 
the  upper  part  of  the  tube,  where  it  can  be  roughly  estimated 
by  the  amount  of  depression  of  the  liquid  column.  When  the 
digestive  process  is  healthy  little  or  no  gas  is  observed  at  the 
end  of  three  hours,  but  in  cases  of  gastric  dilatation  a  sufficient 
quantity  may  be  formed  in  that  time  to  occupy  from  half  an 
inch  to  two  inches  of  the  tube.  This  evidence  of  excessive 
fermentation,  if  combined  with  an  absence  of  free  hydrochloric 
acid  and  an  excess  of  lactic  acid,  constitutes  valuable  confirma- 
tory evidence  of  malignant  disease  of  the  stomach.  The  gas 
collected  in  this  manner  or  which  is  eructated  by  the  patient 
consists  approximately  of  nitrogen  (33-47  per  cent.),  carbon 
dioxide  (13-26  per  cent.),  hydrogen  (21-32  per  cent.),  and 
oxygen  (6-12  per  cent.),  with  a  variable  quantity  of  marsh  gas 
and  of  sulphuretted  hydrogen. 

Carbonic  acid  gas  is  chiefly  derived  from  carbohydrate 
fermentation,  and  especially  from  that  which  converts  lactic 
acid  into  butyric  acid ;  but  it  may  also  be  formed  during  the 
process  of  alcoholic  fermentation.  Hydrogen  occurs  as  a  by- 
product in  the  manufacture  of  butyric  acid  ;  while  the  nitrogen 
and  oxygen  are  introduced  into  the  stomach  in  the  air  which  is 
swallowed  with  the  food  and  saliva.  The  coexistence  of  marsh 
gas  and  hydrogen  renders  the  gas  inflammable.  This  was 
first  demonstrated  by  Hoppe-  Seyler  and  Ivuhn,  and  has  since 
been  investigated  by  Van  Tieghem,  M'Naught,  Ewald,  and 
others.  It  would  appear  that  marsh  gas  is  rarely  generated  in 
the  stomach,  but  frequently  regurgitates  from  the  intestine  in 
cases    of    incompetency   of    the    pylorus.     The    presence    of 


SYMPTOMATOLOGY  129 

sulphuretted  hydrogen  may  be  explained  in  a  similar  manner, 
although  there  is  reason  to  believe  that  this  gas  is  occasionally 
produced  in  the  stomach  itself. 

Acidity. — Burning  sensations  at  the  epigastrium,  followed 
by  scalding  in  the  chest  and  throat  and  the  regurgitation  of 
an  acid  fluid  which  sets  the  teeth  on  edge,  are  much  less 
frequent  in  carcinoma  than  in  simple  ulcer  of  the  stomach. 
They  are  apt  to  occur,  however,  as  an  early  symptom  of 
pyloric  stenosis,  and  even  after  vomiting  has  set  in  regurgita- 
tions of  acid  may  accompany  the  attacks  of  flatulence.  The 
symptom  is  most  common  during  the  night,  and  is  relieved  by 
emesis.  It  is  due  to  excessive  fermentation  of  the  retained 
food,  whereby  lactic  and  butyric  acids  are  produced  in  large 
quantities,  which  give  rise  to  irritation  of  the  stomach. 

Water-orasli  is  a  frequent  symptom,  especially  when  the 
cardiac  end  is  the  seat  of  the  growth,  and  sometimes  precedes  the 
other  indications  of  disease  by  several  weeks.  It  often  occurs 
in  the  intervals  of  digestion,  or  just  before  a  meal,  and  is 
accompanied  by  a  constrictive  pain  at  the  epigastrium  and  the 
regurgitation  of  an  ounce  or  two  of  thin  insipid  fluid.  Some- 
times severe  pain  is  experienced  in  the  chest  and  between  the 
shoulders,  or  the  attack  is  accompanied  by  palpitation.  The 
fluid  itself  is  neutral  or  alkaline  in  reaction,  and  consists 
almost  exclusively  of  saliva.  The  pain  and  regurgitation  probably 
arise  from  a  spasmodic  contraction  of  the  oesophagus. 

The  Tongue. — This  presents  no  special  features,  but  varies 
in  appearance  in  different  cases  and  at  different  periods  of  the 
complaint.  In  32  per  cent,  of  our  cases  it  was  described  as 
'  clean  '  or  '  normal,'  while  in  the  remaining  68  per  cent, 
it  presented  a  greyish-brown  or  creamy  fur,  and  was  often 
stained  with  medicine.  A  moist  and  thickly  coated  tongue 
almost  always  accompanies  excessive  vomiting ;  but  when  pain 
is  the  chief  feature  of  the  case  the  organ  is  apt  to  be 
abnormally  red,  dry,  and  fissured.  During  the  later  stages  of 
the  disease  it  is  often  attacked  by  thrush.  Alteration  or 
loss  of  taste  is  frequently  observed,  and  causes  the  patient  to 
regard  his  food  as  insipid,  pasty,  slimy,  bitter,  metallic,  or 
nauseous.  Sudden  aberration  of  taste  sometimes  marks  the 
onset  of  melancholia  or  delusional  insanity. 

State  of  the  Bowels. — Constipation  almost  always  accom- 
panies the  onset  of  the  disease,  and  becomes  gradually  more 

K 


130  CANCEE   OF  THE   STOMACH 

and  more  pronounced  as  the  case  proceeds.  As  an  early 
symptom  it  existed  in  79  per  cent,  of  our  cases  where  the  pylorus 
was  affected,  and  in  36  per  cent,  of  those  in  which  the  cardiac 
end  of  the  stomach  was  primarily  involved.  It  is  probable  that 
the  inactivity  of  the  bowel  depends  partly  upon  the  diminished 
quantity  of  food  which  enters  it,  and  partly  upon  the  loss  of 
fluid  entailed  by  excessive  vomiting.  In  nearly  4  per  cent,  of 
our  cases  the  constipation  was  eventually  replaced  by  intestinal 
obstruction.  As  a  rule  this  condition  was  the  result  of  direct 
invasion  of  the  transverse  colon  by  the  malignant  growth,  but 
occasionally  it  was  due  to  the  formation  of  an  abscess  between 
the  stomach  and  tbe  bowel,  to  occlusion  of  the  duodenum,  or 
to  cancerous  peritonitis.  In  one  case  a  second  primary  growth 
in  the  rectum  gave  rise  to  a  stricture. 

Diarrhoea  constituted  an  early  symptom  in  4  per  cent,  of 
our  pyloric  cases,  and  in  13  per  cent,  of  those  where  the  disease 
involved  the  cardia.  It  is  probably  due  to  chronic  irritation 
of  the  intestine  by  the  acid  products  of  fermentation.  When 
diarrhoea  replaces  constipation  at  a  late  period  of  the  complaint, 
it  usually  arises  either  from  sloughing  of  a  pyloric  growth  or 
from  the  establishment  of  a  gastro-intestinal  fistula. 

(6)  Failure  of  Strength. — Among  the  various  subjective 
symptoms  that  accompany  a  cancerous  growth  of  the  stomach, 
gradual  loss  of  strength  is  often  the  first  to  attract  attention. 
Although  inclined  for  work,  the  patient  experiences  a  sense 
of  weariness  and  lassitude  in  the  afternoon  which  renders 
him  irritable  and  restless.  Gradually  he  finds  that  he  is 
unable  to  pursue  his  avocation  for  the  whole  day,  and  is 
forced  either  to  curtail  his  hours  of  business  or  to  rest  upon 
his  back  from  time  to  time.  In  other  cases  loss  of  energy  is 
more  apparent  than  physical  debility,  so  that  a  man  who  has 
always  been  remarkable  for  early  rising  and  devotion  to  out- 
door exercise  will  decline  to  get  up  at  the  usual  hour  or  to 
engage  in  any  active  pursuit.  This  change  of  habit  is  often 
so  marked  that  medical  advice  is  sought  on  account  of  some 
supposititious  derangement  of  the  mind,  and  on  more  than  one 
occasion  we  have  known  elderly  people  suffering  from  carci- 
noma of  the  stomach  condemned  as  hysterical,  self-indulgent, 
or  incurably  lazy,  owing  to  their  invincible  objection  to 
physical  or  mental  exertion.  In  many  cases,  however,  careful 
examination  will  show  that  for  some  time  there  has  been  a 
steady  loss  of  flesh,  or  that   the   debility  is   accompanied   by 


SYMPTOMATOLOGY  131 

progressive  anaemia  and  disinclination  for  food  ;  while  in  others , 
and  especially  in  those  where  the  patient  is  engaged  in  a 
sedentary  occupation,,  difficulty  of  mental  concentration,  dizzi- 
ness, failure  of  memory,  or  want  of  decision  accompanies 
the  failure  of  strength.  Finally,  great  depression  of  spirits, 
religious  melancholy,  or  even  delusional  insanity,  is  some- 
times associated  with  deterioration  of  the  general  health. 

(7)  Loss  of  Flesh. — Progressive  emaciation  is  an  invariable 
symptom.  At  first  the  loss  of  flesh  is  only  slight,  and  if  it 
attracts  attention  is  usually  attributed  to  the  indigestion  or 
loss  of  appetite ;  but  with  the  progress  of  the  complaint  the 
weekly  loss  steadily  increases,  until  it  may  amount  to  five 
pounds  or  more.  In  our  hospital  cases  the  total  loss  was 
found  to  vary  according  to  the  duration  of  the  disease,  the 
situation  of  the  growth,  and  the  sex  of  the  patient.  Thus,  in 
the  male  cases  the  average  weight  at  the  time  of  death  was 
111  pounds,  and  in  the  female  ninety-one  pounds  ;  and  since 
the  average  weight  of  a  healthy  male  at  fifty  years  of  age  is 
148  pounds,  and  of  a  female  128  pounds,  there  was  loss  in  the 
former  sex  of  25  per  cent.,  and  in  the  latter  of  29  per  cent,  of 
the  total  weight  of  the  body.  In  both  sexes  the  loss  was 
greater  when  the  disease  occurred  below  the  age  of  forty-five 
years  than  after  that  period.  The  emaciation  was  also  more 
severe  when  the  orifices  of  the  stomach  were  affected  than 
when  the  body  of  the  viscus  was  the  seat  of  disease.  Thus, 
with  growths  of  the  cardia  and  pylorus  the  average  weight  in 
males  at  the  time  of  death  was  109  and  110  pounds  respec- 
tively, while  in  disease  of  the  central  region  of  the  organ  it 
amounted  to  114  pounds.  The  occurrence  of  multiple  deposits 
in  the  liver  and  other  viscera  appeared  to  compensate  in  some 
degree  for  wasting  of  the  soft  tissues,  since  in  these  cases  the 
average  weight  at  death  amounted  to  115  pounds.  It  must 
be  borne  in  mind,  however,  that  the  production  of  metastases 
always  hastens  the  fatal  termination,  and  consequently  curtails 
the  period  of  emaciation.  The  average  loss  of  weight  per  week 
in  the  various  cases  was  as  follows  : 


Under  1  pound  in 

1  to  2  pounds  in 

2  to  3  pounds  in 

3  to  4  pounds  in 

4  to  5  pounds  in 


26% 
35% 
21% 
16% 
2% 

100% 

k  2 


132  CANCEE  OF  THE   STOMACH 

In  15  per  cent,  of  the  entire  number  an  initial  gain  was 
observed,  which  lasted  from  ten  days  to  three  weeks  and 
varied  in  amount  from  two  to  eleven  pounds.  In  all  these 
cases  the  patient  was  suffering  from  obstruction  of  the  cardiac 
or  pyloric  orifice,  so  that  the  improvement  which  was  manifested 
ma3*  be  ascribed  to  the  better  methods  of  feeding  which  the 
patients  enjoyed  when  they  entered  the  hospital. 

Occasionally  this  improvement  is  of  much  longer  duration 
and  the  gain  in  weight  is  considerable.  In  a  case  recorded 
by  Keen  and  Stewart  the  patient  put  on  sixty-three  pounds  of 
flesh  within  four  months  of  an  exploratory  laparotomy  which 
confirmed  the  existence  of  carcinoma.  In  other  instances  an 
increase  of  appetite,  renewed  hope  of  recovery,  the  employment 
of  rectal  feeding,  or  the  performance  of  gastrostomy  or  gastro- 
enterostomy is  followed  by  a  steady  gain,  which  lasts  for 
several  weeks.  On  the  other  hand,  extension  of  the  disease  to 
the  oesophagus  or  pylorus  rapidly  augments  the  progress  of 
the  emaciation.  A  sudden  increase  of  weight  usually  indicates 
effusion  of  fluid  into  the  peritoneal  or  pleural  cavities  or  a 
rapid  invasion  of  the  liver. 

As  a  rule  the  superfluous  fat  of  the  body,  and  especially  that 
situated  in  the  omentum  and  mesentery,  is  the  first  tissue  to 
undergo  absorption.  In  consequence  of  this  stout  people  will 
frequently  remark  upon  their  diminution  in  girth  before  their 
attention  is  attracted  to  the  wasting  of  other  parts.  Next  to 
the  abdomen,  the  mamma;,  neck,  cheeks,  and  hips  exhibit  the 
earliest  loss  of  substance,  and  the  skin  becomes  loose,  flabbj^, 
and  devoid  of  elasticity.  All  the  voluntary  muscles  become 
attenuated,  the  first  to  show  signs  of  atrophy  being  the 
adductors  of  the  thighs,  the  pectorals,  the  gastrocnemii,  the 
interossei  in  the  hands,  and  the  temporals.  Among  the 
internal  viscera,  the  heart  and  spleen  are  more  affected  than  the 
liver  and  kidneys  (p.  72).  The  diminished  power  of  absorp- 
tion and  the  excessive  quantity  of  fluid  lost  by  vomiting  also 
contribute  to  the  general  loss  of  weight,  and  produce  the 
sunken  appearance  of  the  eyes  and  the  shrivelled  claw-like 
hands,  which  invariably  attract  attention  during  the  later  stages 
of  the  complaint.  In  many  cases  the  failure  of  nutrition  is 
accompanied  by  a  rapid  whitening  or  falling  out  of  the  hair, 
and  occasionally  the  long  bones  grow  thin  and  brittle  and  are 
unduly  prone  to  fracture. 


SYMPTOMATOLOGY  133 

(8)  Anaemia  (Cachexia).— Loss  of  colour  has  long  been 
recognised  as  one  of  the  most  striking  features  of  malignant 
disease,  and  extreme  pallor  of  the  lips  and  conjunctivae  is  always 
a  prominent  symptom  of  the  gastric  complaint.  The  anaemia 
is  usually  most  pronounced  when  the  growth  has  undergone 
ulceration  or  has  given  rise  to  metastases  in  the  liver  and  other 
viscera.  It  is  also  a  marked  feature  in  cases  which  present  a 
constant  elevation  of  temperature.  An  intense  form,  which 
is  accompanied  by  a  lemon  tint  of  the  skin  and  is  closely  com- 
parable to  that  of  idiopathic  or  pernicious  anaemia,  is  met  with 
in  about  18  per  cent,  of  all  cases.  The  changes  which  occur 
in  the  blood  are  partly  due  to  the  absorption  of  the  chemical 
products  of  the  new  growth,  but  chiefly,  we  believe,  to  fre- 
quent small  haemorrhages,  since  in  almost  every  case  of  pro- 
found anaemia  there  is  either  a  history  of  repeated  haematemesis 
or  the  contents  of  the  stomach  when  withdrawn  by  a  tube 
constantly  contain  altered  blood  (p.  121).  The  total  quantity  of 
blood  in  the  body  becomes  gradually  reduced  as  the  disease 
progresses,  and  its  density  also  diminishes.  This  latter  feature 
is  particularly  noticeable  when  the  haemoglobin  percentage 
is  very  low  (Schmalz,  Lyonnet). 

Bed  Corpuscles. — In  every  case  there  is  a  notable  diminu- 
tion in  the  number  of  red  corpuscles  (Laache).  The  average 
number  at  the  time  when  the  tumour  becomes  palpable  is 
about  3,500,000  per  cubic  millimetre,  though  occasionally  it 
reaches  5,000,000  or  falls  as  low  as  1,500,000.  A  relatively 
high  count,  or  even  polycythaemia,  is  occasionally  encountered 
in  cases  of  pyloric  stenosis  accompanied  by  excessive  vomiting. 
It  is  worthy  of  notice  that  the  corpuscular  richness  in  gastric 
cancer  seldom  increases  under  treatment,  but  at  the  same 
time  the  number  of  red  cells  rarely  falls  below  1,500,000  per 
cubic  millimetre.  The  former  peculiarity  serves  to  distinguish 
the  disease  from  many  other  forms  of  secondary  anaemia,  and 
the  latter  from  the  pernicious  variety,  where,  according  to 
Henry,  the  cells  always  number  less  than  1,000,000  per  cubic 
millimetre  before  death  occurs.  When  stained  films  are 
examined  by  the  microscope,  the  red  corpuscles  show  moderate 
variations  of  shape,  and  not  infrequently  poikilocytosis.  Lepine 
has  observed  microcytes  in  such  numbers  that  they  equalled 
half  the  total  number  of  red  cells ;  while  other  writers  have 
described   the   presence   of    nucleated    corpuscles    of    various 


134  CANCEE   OF  THE   STOMACH 

sizes.     Typical  inegaloblasts,  however,  are  rarely,  if  ever,  en- 
countered. 

White  Corpuscles. — An  increase  in  the  number  of  white 
corpuscles  (leucocytosis)  occurs  in  the  majority  of  the  cases, 
and  is  most  frequent  in  growths  of  the  medullary  or  cylindrical- 
cell  type,  but  it  is  not  apparently  influenced  by  the  presence  of 
ulceration  or  of  metastases.  It  is  often  very  marked  when  the 
disease  is  accompanied  by  pyrexia  or  by  a  localised  abscess  in 
the  peritoneum.  If  the  normal  number  of  white  cells  is  reckoned 
at  7,000  per  cubic  millimetre  of  blood,  nearly  60  per  cent,  of 
all  cases  of  gastric  cancer  exhibit  an  excess,  while  more  than 
25  per  cent,  present  15,000  to  25,000  per  cubic  millimetre. 
This  latter  number,  which  was  observed  in  three  cases  of  our 
series,  has  induced  Alexandre  and  other  writers  to  describe  a 
special  variety  of  the  disease  by  the  term  '  Leuchsemic 
Cancer.' 

Microscopical  examination  of  a  stained  film  always  shows  a 
slight  excess  of  polymorphonuclear  cells ;  and  according  to 
Sailer  and  Taylor  there  is  often  a  preponderance  of  the  large 
mononuclear  forms  over  the  lymphocytes.  Van  Valzah  and 
Nisbet  state  that  myelocytes  are  frequently  present,  but  this  is 
disputed  by  Osier  and  McCrae.  Eosinophiles  occur  in  small 
numbers. 

Digestion  Leucocytosis. — Under  normal  conditions  the 
number  of  white  cells  in  the  blood  is  increased  during  the 
period  of  gastric  digestion,  and  a  similar  phenomenon  is 
observed  in  chronic  ulcer  and  in  most  of  the  functional  dis- 
orders of  the  stomach.  In  malignant  disease,  however,  Miiller 
states  that  this  temporary  leucocytosis  usually  fails,  and  his 
observations  have  been  confirmed  by  Riecler,  Schneyer,  and 
Hartung.  The  last-named  has  also  observed  a  similar  absence  in 
cases  of  atrophy  of  the  stomach  secondary  to  carcinoma  of  the 
breast.  On  the  other  hand,  Osier  and  McCrae  observed  digestion 
leucocytosis  in  nearly  one  half  of  the  cases  they  examined,  a 
result  which  tallies  closely  with  our  own  experience.  It  must 
therefore  be  admitted  that  while  the  absence  of  digestion  leuco- 
cytosis may  help  to  confirm  a  diagnosis  of  carcinoma,  its 
presence  in  no  way  negatives  a  suspicion  of  malignant  disease. 

Hemoglobin. — The  colouring  matter  of  the  blood  is  in- 
variably reduced,  the  average  quantity  varying  from  50  to  30 
per  cent,  of  the  normal.     The  haemoglobin  value  of  the  indi- 


SYMPTOMATOLOGY 


135 


vidual  corpuscles  is  also  diminished  to  a  much  greater  extent 
than  in  cases' of  pernicious  anaemia  (Lepine). 

(9)  Temperature. — The  absence  of  fever  in  cancer  generally 
has  led  to  the  impression  that  malignant  disease  of  the  stomach 
is  a  non-febrile  complaint.  As  a  matter  of  fact,  however, 
nearly  one  third  of  all  cases  of  gastric  carcinoma  exhibit  an 
elevation  of  temperature  at  some  period  of  their  course,  while 
occasionally  the  pyrexia  is  so  prolonged  and  severe  as  to  lead 
to  serious  errors  of  diagnosis  (Hampeln,  Devic  and  Chatin, 
Hanot).  An  analysis  of  our  cases  with  reference  to  this  point 
gives  the  following  results  : 


Temperature  normal  or  subnormal  in 

Occasional  elevation  in 

Constant  elevation  in     .         .         .    <■ 


68% 
17% 
15% 


In  the  apyrexial  cases,  which  constitute  about  two-thirds  of 
the  entire  number,  the  temperature  remains  at  or  just  below 
the  normal  point  until  a  week  or  two  before  death,  when  it 
steadily  falls  to  97°  or  96°  F.  Even  in  this  condition,  however, 
diurnal  variations  may  still  be  observed.  The  lowest  tempera- 
tures are  usually  met  with  in  the  autumn  and  winter  months. 


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Fig.    30. — Chart  showing  the  depressed  temperature  which  usually  accom- 
panies the  later  stages  of  the  disease.  (London  Temperance  Hospital.) 


Occasional  attacks  of  fever  may  occur  throughout  the  entire 
course  of  the  disease,  or  they  may  develop  only  during  its  later 
stages.  In  the  former  case  the  sudden  rise  of  temperature  is 
often  accompanied  by  chills,  headache,  or  pains  in  the  limbs, 
and  the  mercury  in  the  thermometer  may  rise  to  102°  or  103°  F., 
and  remain  at  this  point  for  two  or  three  days.     If  deferves- 


136 


CANCEE  OE  THE   STOMACH 


cence  takes  place  suddenly,  it  is  often  accompanied  by  sweat- 
ing, vomiting,  or  diarrhoea,  but  when  the  fall  occurs  gradually  it 
is  not  attended  by  special  symptoms.  Between  the  attacks  the 
evening  temperature  often  rises  to  99°  F. 


Fig.  31. — Chart  of  a  case  of  adeno-carcinorna  of  the  body  of  the  stomach,  show- 
ing occasional  attacks  of  fever.     (London  Temperance  Hospital.) 

Continued  fever  occurs  in  several  forms.  As  a  rule  it  is 
distinctly  remittent,  the  evening  reading  being  100-101°  and 
the  morning  99-100°  F.  In  other  cases  the  temperature  always 
falls  below  normal  in  the  morning,  and  the  chart  consequently 


Fig.  32. — Chart  of  a  case  of  soft  cancerous  growth  of  the  posterior  wall  of  the 
stomach,  showing  continued  fever.     (London  Temperance  Hospital.) 


resembles  one  of  suppuration  or  chronic  phthisis.  Both 
varieties  may  continue  for  several  months,  but  with  the  progress 
of  exhaustion  the  evening  exacerbations  become  less  marked, 
until  an  apyrexial  condition  supervenes.  Finally,  in  rare  cases 
the  temperature  remains  constantly  elevated  above  100°  F.,  and 


SYMPTOMATOLOGY 


137 


is  accompanied  by  shiverings,  sweatings,  and  other  indications 
of  septicaemia. 

The  origin  of  the  fever  has  been  variously  attributed  to 
ulceration  of  the  growth,  to  the  presence  of  metastases,  to 
inflammation  of  the  peritoneum,  to  general  carcinosis,  or  to 
some  other  complication  of  the  disease ;  but  while  it  must  be 
admitted  that  one  or  more  of  these  conditions  are  often  present  in 
febrile  cases,  their  not  infrequent  absence  seems  to  indicate  that 
none  of  them  are  absolutely  essential  to  the  production  of  pyrexia. 
A  careful  examination  of  the  cases  that  occurred  in  our  series 


Fig.  33. — Chart  of  septicaemia  arising  from  cancer  of  the  stomach. 
(London  Temperance  Hospital.) 


indicates  that  the  temperature  varies  according  to  (a)  the  situa- 
tion and  character  of  the  neoplasm,  (b)  the  severity  of  certain 
symptoms,  and  (c)  the  presence  of  secondary  inflammation  in 
the  peritoneal  or  thoracic  cavity. 

(a)  In  the  following  table  we  have  arranged  the  cases 
according  to  the  site  of  the  disease  and  the  character  of  the 
temperature.  It  will  be  observed  that  when  the  neoplasm 
involved  the  pylorus  febrile  symptoms  were  present  in  only 
20  per  cent.,  while  in  disease  of  the  body  of  the  stomach  and 
of  the  cardia  they  existed  in  58  per  cent,  and  37  per  cent, 
respectively. 

Table  27 


Site  of  disease 

No  fever 

Occasional  fever 

Constant  fever 

Pylorus    .... 
Cardia      .... 
Walls  and  curvatures 

80% 
63% 
42% 

11% 
12% 
25% 

9% ' 
25% 
33% 

138 


CANCER   OF  THE   STOMACH 


It  has  already  been  shown  that  morbid  growths  vary  in 
character  in  different  regions  of  the  stomach,  those  which 
occupy  the  pylorus  being  often  hard,  contractile,  and  prone  to 
superficial  ulceration,  while  those  situated  upon  the  walls  or 
curvatures  of  the  organ  are  usually  soft,  rapidly  growing,  and 
liable  to  slough.  It  is  possible,  therefore,  that  the  variations  of 
temperature  may  depend  as  much  upon  the  morphological  pecu- 
liarities of  the  tumour  as  upon  its  situation.  This  suggestion  is 
supported  by  the  fact  that  while  an  elevation  of  temperature  was 
only  observed  in  11  per  cent,  of  the  cases  of  scirrhus,  nearly  53 
per  cent,  of  those  described  as  medullary  or  adeno-carcinomata 
were  accompanied  by  pyrexia.  Of  these  latter  cases,  the  great 
majority  presented  ulceration  or  metastases  after  death,  but  in 


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Fig.  154. — Chart  in  a  case  of  carcinoma  of  the  stomach  which  proved 
fatal  from  pneumonia.       (London  Temperance  Hospital.) 


8  per  cent,  the  growth  was  not  associated  with  any  complica- 
tion visible  to  the  naked  eye.  It  is  therefore  probable  that  the 
softer  forms  of  carcinoma,  like  certain  sarcomata,  are  often 
attended  by  moderate  pyrexia  as  the  result  of  an  extreme 
activity  of  cell-growth. 

(b)  The  symptoms  which  exert  the  most  important  iufluence 
upon  the  temperature  are  dysphagia  and  vomiting.  In  every  case 
where  the  disease  was  accompanied  by  difficulty  of  swallowing 
the  temperature  showed  the  same  tendency  to  depression  that 
occurs  in  other  forms  of  starvation,  and  for  many  weeks  before 
death  indicated  a  state  of  collapse.  The  antipyretic  effect  of 
excessive  vomiting  may  be  due  partly  to  progressive  inanition, 
and  partly  to  the  elimination  of  pyogenetic  substances  pro- 


SYMPTOMATOLOGY  139 

duced  by  the  disintegration  of  the  neoplasm.  In  our  series 
fever  was  present  in  53  per  cent,  of  those  where  vomiting  was 
rare  or  absent,  but  only  in  9  per  cent,  of  those  attended  by 
frequent  attacks  of  emesis. 

(c)  Certain  complications  are  usually  accompanied  by 
fever,  especially  inflammations  of  the  peritoneum,  pleura,  and 
lung.  In  exactly  one  half  of  our  cases  where  the  temperature 
remained  constantly  elevated,  recent  peritonitis  was  found  in 
the  upper  segment  of  the  abdomen  after  death.  In  most 
instances  this  was  due  to  malignant  infection  of  the  serous 
membrane,  but  in  two  perigastric  suppuration  had  occurred 
from  leakage  through  the  base  of  the  disease.  Exudation  into 
the  pleura  or  acute  pneumonia  is  often  responsible  for  the 
pyrexia  that  develops  during  the  last  week  of  life  (fig.  34). 

(10)  The  Saliva. — As  a  rule  the  saliva  presents  no  deviation 
from  the  normal  either  in  quantity  or  appearance.  Occa- 
sionally, however,  the  secretion  is  considerably  increased  or  is 
unduly  thick  and  glutinous.  A  large  proportion  of  the  slimy 
mucus  which  is  vomited  in  the  early  morning  consists  of 
saliva  that  has  been  swallowed  during  the  night.  In  every 
case  of  carcinoma  of  the  stomach  there  is  a  great  diminution 
of  the  sulphocyanide  of  potassium.  During  the  early  stages  of 
the  disease  the  decrease  may  not  be  very  marked,  but  as  soon 
as  the  general  nutrition  becomes  seriously  impaired  the  propor- 
tion of  the  salt  steadily  diminishes,  and  it  finally  disappears 
altogether.  In  cases  of  simple  ulcer,  on  the  other  hand,  the 
quantity  is  rarely  reduced  unless  the  disease  is  attended  by 
excessive  emaciation. 

The  production  of  sulphocyanide  of  potassium  and  its 
elimination  in  the  saliva  appear  to  depend  upon  three  factors, 
viz.  the  rapidity  of  absorption,  the  integrity  of  the  hepatic 
cells,  and  the  secretory  activity  of  the  salivary  glands.  Thus, 
any  condition  which  lessens  the  absorption  of  peptones,  such 
as  excessive  vomiting,  atrophy  of  the  stomach  and  intestine, 
obstruction  of  the  oesophagus,  or  deprivation  of  food,  is  always 
accompanied  by  a  diminished  elimination  of  the  salt ;  and 
the  same  occurs,  though  in  a  lesser  degree,  in  cases  of  obstruc- 
tion to  the  portal  circulation.  The  secretion  of  sulphocyanide 
of  potassium,  like  that  of  urea,  is  dependent  upon  the  metabolic 
activity  of  the  hepatic  cells.  Chronic  poisoning  by  such  sub- 
stances  as   lead,  phosphorus,  and    arsenic,  which  retard   the 


140  CANCEE  OF  THE   STOMACH 

functions  of  the  liver,  or  such  diseases  as  acute  yellow  atrophy 
and  diffuse  cirrhosis,  which  destroy  the  tissue  of  the  organ,  are 
always  accompanied  by  a  diminution  in  the  quantity  of  the  salt ; 
while  excessive  salivation  from  mercury  and  continued  fevers, 
which  lead  to  functional  disorder  of  the  salivary  glands,  is 
productive  of  a  similar  result. 

The  main  factor  in  the  diminished  production  of  the 
sulphocyanide  in  gastric  carcinoma  seems  to  be  the  impair- 
ment of  digestion  and  absorption  which  results  from  the 
disease.  It  is,  consequently,  most  noticeable  in  cases  where  the 
cardiac  orifice  is  obstructed  or  vomiting  is  an  urgent  symptom. 
As  an  element  in  the  prognosis  we  consider  the  total  disap- 
pearance of  the  salt  to  be  of  the  greatest  importance,  for  we 
have  never  known  a  case  to  live  for  more  than  a  month  after 
this  phenomenon  had  been  observed.  It  is  important,  however, 
to  remember  that  a  patient  who  presents  no  sulphocyanide 
when  seen  for  the  first  time,  will  often  exhibit  a  renewed 
elimination  of  the  salt  when  he  is  placed  under  more  favourable 
conditions  and  treated  by  lavage  and  rectal  feeding. 

As  a  rule  the  quantity  of  sulphocyanide  of  potassium 
present  in  the  saliva  may  be  gauged  with  sufficient  accuracy 
by  comparing  the  colour  produced  by  the  addition  of  two 
drops  of  a  solution  of  perchloride  of  iron  (two  drachms  to  the 
ounce)  to  the  saliva  of  the  patient  with  that  of  a  healthy 
individual.  For  more  accurate  work  we  are  in  the  habit  of 
employing  a  tintometer  the  scale  of  which  represents  quantities 
of  the  sulphocyanide  varying  from  -05  to  '7  mgs.  The 
patient  is  requested  to  produce  as  much  saliva  as  possible  for 
two  minutes,  and  to  each  cubic  centimetre  of  the  secretion  are 
added  two  drops  of  the  solution  of  ferric  perchloride.  The 
mixture  is  then  stirred  with  a  glass  rod  and  filtered  through 
cotton-wool,  after  which  it  is  compared  with  the  tintometer 
scale.1 

(11)  The  Urine. — The  quantity  of  urine  is  invariably 
diminished.  When  the  body  of  the  stomach  is  the  seat  of 
disease,  and  pain  is  the  principal  symptom,  the  daily  amount 
may  exceed  thirty  fluid  ounces  ;  but  if  the  orifices  are  involved 
or  vomiting  is  severe,  only  about  fifteen  fluid  ounces  may  be 
voided  in  the  twenty-four  hours.     Both  the  colour  and   the 

1  Vide  Samuel  Fenwick,  The  Saliva  as  a  Test  for  Functional  Diseases  of  the 
Liver,  1887. 


SYMPTOMATOLOGY  141 

specific  gravity  are  somewhat  increased,  and  if  numerous 
metastases  are  present  in  the  liver  an  excess  of  urobilin  may 
be  observed  (Tissier).  An  odour  of  acetone  is  often  detected 
during  an  intercurrent  attack  of  subacute  gastritis,  and  the 
existence  of  diacetic  acid  may  be  demonstrated  by  the  blood- 
red  colouration  which  is  produced  by  the  addition  of  per- 
chloride  of  iron  (Jaksch).  Oxybutyric  acid  is  also  occasionally 
found  (Klemperer).  Senator  has  shown  that  excessive  putre- 
faction of  the  intestinal  contents,  with  constipation,  may  be 
accompanied  by  the  elimination  of  indican.  A  simple  test  for 
this  substance  consists  in  mixing  equal  parts  of  urine  and 
strong  hydrochloric  acid  in  a  stoppered  bottle,  and  adding  one 
drop  of  a  solution  of  calcium  hypochlorite  and  one  cubic 
centimetre  of  chloroform.  After  shaking  for  a  few  minutes 
the  indican  is  converted  into  indigo,  which  produces  a  deep 
blue  colouration  of  the  fluid. 

Although  chronic  interstitial  nephritis  existed  in  15  per 
cent,  of  our  cases,  albuminuria  was  observed  in  only  3  per 
cent.  A  large  quantity  of  albumin  is  usually  indicative  of 
parenchymatous  nephritis,  infarction,  or  of  secondary  growths 
in  the  kidney.  Peptonuria  has  been  observed  by  Maixner  and 
Parganowski.  By  the  former  it  was  attributed  to  a  loss  of  func- 
tional activity  on  the  part  of  the  gastric  mucous  membrane,  and 
by  the  latter  to  the  production  of  peptone  by  the  disintegration 
of  the  cancerous  growth. 

The  quantity  of  urea  which  is  excreted  varies  considerably. 
During  the  early  stages  of  the  complaint,  and  in  cases  that 
pursue  an  acute  course,  the  daity  output  may  be  increased  owing 
to  the  rapid  wasting  of  the  tissues  ;  but  with  the  progress  of 
inanition  the  amount  gradually  diminishes,  until  it  may  average 
only  twenty  to  twenty-five  grammes  in  the  twenty-four  hours. 
The  diminution  is  much  greater  when  the  pylorus  or  the  cardiac 
orifice  is  obstructed,  for  in  such  cases  the  total  may  not  exceed 
ten  to  fifteen  grammes.  Eommelaere  believes  that  the  elimi- 
nation of  less  than  twelve  grammes  of  urea  per  diem  by  a  patient 
who  suffers  from  chronic  indigestion  is  pathognomonic  of  gastric 
cancer  ;  but  the  researches  of  Eobin,  Kirmisson,  and  Deschamps 
have  shown  that  a  similar  diminution  of  the  salt  may  accom- 
pany non-malignant  affections  of  the  stomach.  It  is  permis- 
sible, however,  to  assume  that  carcinoma  does  not  exist  in  a 
case  where  the  daily  quantity  of  urea  exceeds  thirty  grammes. 


142  CANCBE  OF  THE   STOMACH 

As  a  rule  the  chlorides  are  greatly  diminished,  and  this 
fact  is  regarded  by  Jaccoud  as  one  of  great  clinical  importance. 
It  is  probable,  however,  that  the  percentage  amount  of 
chlorides  in  the  urine  does  not  depend  so  much  upon  the 
existence  of  carcinoma  as  upon  the  degree  of  inanition  with 
which  it  is  attended.  Thus,  Bouveret  has  observed  an  excess 
of  these  salts  when  the  body  of  the  stomach  was  affected 
without  obstruction  of  the  orifices,  while  in  cases  which 
suffered  from  excessive  vomiting  or  extreme  dysphagia  less 
than  one  gramme  was  often  voided  in  the  course  of  the 
twenty-four  hours.  It  may  also  be  noted  that  in  many  cases 
of  hypersecretion  secondary  to  chronic  ulcer  the  total  quantity 
of  chlorides  is  reduced  to  a  still  smaller  figure.  An  excess  of 
ethereal  sulphates  is  occasionally  present  when  cancer  of  the 
pylorus  has  given  rise  to  great  dilatation  of  the  stomach. 

(12)  Nervous  Symptoms. — Paralysis  affecting  the  face  or 
one  side  of  the  body  was  observed  in  2  per  cent,  of  our  cases, 
and  was  caused  either  by  ordinary  cerebral  haemorrhage,  a 
metastatic  growth  in  the  brain,  or  by  thrombosis  of  the  basilar 
or  middle  cerebral  arteries. 

Insomnia  is  a  frequent  cause  of  complaint,  especially  towards 
the  termination  of  the  disease,  and  may  be  attributed  partly  to 
nocturnal  attacks  of  pain,  and  partly  to  the  cerebral  anaemia  that 
ensues  from  the  general  malnutrition.  The  delirium  which  is 
sometimes  observed  during  the  last  few  weeks  of  life  is  also 
probably  due  to  the  latter  condition. 

In  contrast  to  the  optimism  displayed  by  the  subjects  of 
tuberculosis,  mental  depression  is  an  invariable  feature  of  gastric 
carcinoma,  and  usually  induces  the  patient  to  take  a  serious 
view  of  his  complaint  long  before  the  development  of  special 
symptoms  suggests  to  his  medical  attendant  the  possible 
existence  of  malignant  disease.  Persons  who  possess  an 
hereditary  predisposition  to  phthisis  or  mental  disorders  not 
infrequently  develop  actual  melancholia  or  suffer  from  delusional 
insanity.  We  have  known  several  cases  where  the  mental 
aberration  was  so  pronounced  as  to  necessitate  the  employment 
of  special  attendants  or  removal  to  an  asylum.  If  these 
phenomena  appear  at  an  early  stage  of  the  disease,  they  often 
mask  the  gastric  affection  and  occasion  serious  errors  of  dia- 
gnosis. Excessive  pain  accompanied  by  insomnia  sometimes 
induces   attempts  at   suicide.     The   occasional  development  of 


SYMPTOMATOLOGY  143 

tetany  and  spinal  paralysis  will  be  discussed  among  the  com- 
plications of  the  disease. 

Certain  cases,  and  especially  those  where  the  growth  is  exten- 
sive, the  anaemia  profound,  and  vomiting  an  infrequent  symptom, 
exhibit  a  peculiar  form  of  coma  during  the  final  phase  of  the 
disease.  This  phenomenon,  to  which  the  term  '  coma  carcino- 
matosum  '  has  been  applied,  was  first  described  by  Petters  and 
Kaulich,  and  later  by  V.  Jaksch,  Eiess,  and  Senator.  Accord- 
ing to  our  experience  it  is  usually  preceded  by  rapid  failure  of 
strength,  disappearance  of  appetite,  a  fall  of  temperature,  and 
occasionally  by  severe  retching  and  vomiting.  The  patient  lies 
motionless  in  bed  and  in  a  state  of  profound  lethargy,  from 
which  he  can  at  first  be  temporarily  aroused,  but  which 
is  soon  transformed  into  genuine  coma.  In  this  condition  the 
breathing  is  quickened,  and  is  characterised  by  deep  inspirations, 
followed  by  long  sighing  expirations.  The  pulse  is  small  and  of 
low  tension,  and  varies  in  frequency  from  time  to  time.  The 
pupils  are  slightly  dilated,  the  tongue  is  dry  and  often  covered 
with  aphthae,  and  the  surface  of  the  body  is  cold  and  blue. 
The  urine  is  retained,  and  the  quantity  secreted  is  greatly 
diminished.  Occasionally  the  sweet  smell  of  acetone  may  be 
recognised  in  the  breath.  Slight  attacks  of  convulsions  are 
sometimes  observed.  The  duration  of  the  coma  varies  from 
twenty-four  hours  to  several  days,  but  after  it  has  become 
profound  life  is  seldom  prolonged  more  than  three  days.  In 
those  cases  which  display  an  extreme  somnolence  rather  than 
actual  coma,  the  patient  may  continue  in  a  lethargic  state  for 
ten  days,  or  even  longer,  provided  that  the  warmth  of  the  body 
and  the  nutrition  are  satisfactorily  maintained.  In  one  instance 
which  came  under  our  care  the  patient  remained  unconscious 
and  unable  to  swallow  food  for  seventeen  days.  Death  usually 
occurs  quite  suddenly  from  failure  of  the  respiration. 

The  great  similarity  between  this  form  of  coma  and  that 
which  attends  diabetes  seems  to  indicate  that  it  also  arises  from 
auto-intoxication.  The  acetone  smell  in  the  breath  and  the 
occurrence  of  oxybutyric  acid  in  the  urine  in  both  forms  of 
coma  are  of  special  interest. 

(13)  (Edema.— The  lower  extremities  frequently  become 
oedematous  during  the  last  month  or  two  of  life,  either  from 
gradual  failure  of  the  circulation  or  from  pressure  of  ascitic 
fluid  or  a  growth  upon  the  inferior  vena  cava.     When  only  one 


144  CANCEE  OP  THE   STOMACH 

limb  is  affected  the  cause  is  to  be  found  in  venous  thrombosis. 
General  anasarca  usually  indicates  secondary  inflammation  of 
the  kidney,  but  occasionally  it  exists  without  albuminuria  or 
other  signs  of  renal  disease,  and  may  be  associated  with  ascites 
and  hydrothorax.  Chesnel  has  collected  twelve  instances  of 
this  interesting  condition,  and  attributes  it  to  an  alteration  in 
the  composition  of  the  blood. 


145 


CHAPTEK   V 
PHYSICAL   SIGNS 

The  general  aspect  of  a  person  suffering  from  carcinoma  of  the 
stomach  is  often  highly  suggestive  of  the  nature  of  his  com- 
plaint. When  pain  has  been  a  prominent  symptom  the  thin 
pinched  face,  the  pursed-up  mouth,  and  the  permanent  furrow 
at  the  root  of  the  nose  between  the  eyebrows  convey  to  the 
mind  an  impression  of  constant  suffering  ;  while  the  sallow  skin, 
the  sunken  cheeks,  and  the  hollow  temples  so  frequently  seen  in 
cases  of  pyloric  stenosis  indicate  an  impairment  of  nutrition 
that  is  rarely  met  with  except  in  malignant  disease  of  the 
stomach.  Jn  addition  to  this,  the  briskness  of  movement,  the 
activity  of  thought,  and  the  energy  of  expression  usual  in  a  man 
in  the  prime  of  life  are  replaced  by  a  feeble  gait  and  a  listless 
demeanour,  which  show  that  every  effort  has  become  a  toil,  and 
that  a  sense  of  extreme  weariness  prevents  the  patient  from 
taking  any  interest  in  the  daily  affairs  of  life.  The  despon- 
dency and  minuteness  of  detail  with  which  he  discusses  the 
most  trivial  features  of  his  dyspepsia  also  strike  the  imagination 
as  being  out  of  proportion  to  the  apparent  seriousness  of  the 
complaint,  and  should  serve  to  warn  the  most  careless  clinician 
of  the  existence  of  something  more  grave  than  a  mere  func- 
tional disturbance  of  digestion. 

Although  anaemia  is  invariably  present,  certain  cases  exhibit 
a  curious  patch  of  colour  upon  either  cheek,  which  stands  out 
in  marked  contrast  to  the  yellowish  pallor  of  the  surrounding 
skin.  This  is  due  to  the  development  of  a  capillary  plexus  over 
the  malar  bones,  which  gradually  increases  in  size  until  it  forms 
a  large  network  of  crimson-coloured  vessels.  According  to  our 
experience  the  phenomenon  is  chiefly  encountered  in  cases 
where  the  malignant  growth  has  involved  the  glands  and  tissues 
behind  the  stomach,  and  seldom  occurs  before  the  sixth  month 
of  the  illness.    The  fact  that  the  semilunar  ganglia  are  frequently 

L 


146  CANCEE  OF  THE   STOMACH 

embedded  in  the  neoplasm  seems  to  indicate  that  sympathetic 
irritation  is  the  cause  of  the  dilatation  of  the  superficial  vessels. 

INSPECTION    OF    THE    ABDOMEN 

Careful  inspection  of  the  abdomen  seldom  fails  to  reveal 
important  information,  while  not  infrequently  the  facts  which 
it  imparts  are  of  the  utmost  possible  value.  In  order  to 
obtain  the  best  results  the  patient  should  lie  upon  his  back 
with  the  occiput  in  contact  with  the  mattress  and  the  light 
thrown  upon  the  body  from  the  side  opposite  to  the  observer. 
The  mouth  should  be  open,  and  he  should  be  directed  to  breathe 
easily  and  fully.  No  talking  ought  to  be  allowed,  and  no 
attempt  should  be  made  to  raise  the  head,  since  it  produces  a 
contraction  of  the  abdominal  muscles,  which  greatly  alters  the 
appearance  of  the  parts.  In  every  case  attention  should  be 
directed  to  the  following  points  :  (a)  The  general  shape  of  the 
abdomen,  (b)  the  position  and  size  of  the  stomach,  (c)  the 
existence  of  visible  peristalsis,  (d)  the  presence  of  a  tumour, 
(e)  dilatation  of  the  superficial  veins,  (/)  retraction  of  the  navel. 

(a)  Shape  of  the  Abdomen. — The  loss  of  the  omental  and 
subcutaneous  fat  that  occurs  at  an  early  period  of  the  complaint 
gives  the  skin  of  the  abdomen  a  loose  appearance,  as  though  it 
were  too  voluminous,  and  in  stout  persons  who  have  wasted 
rapidly  linese  atrophic*  may  often  be  observed  in  the  hypo- 
gastriurn  and  the  flanks.  General  distension  is  usually  a  sign 
of  ascites,  but  occasionally  it  ensues  from  gaseous  inflation  of 
the  intestine  owing  to  obstruction  of  the  colon. 

(b)  Situation  of  the  Stomach. — The  normal  stomach  occupies 
the  left  hypochondrium  and  epigastrium,  and  with  the  trans- 
verse colon  produces  a  slight  protuberance  of  the  abdomen 
above  the  umbilicus.  When  the  organ  is  much  dilated  it 
tends  to  become  displaced  by  its  own  weight,  and  occupies  the 
umbilical  or  even  the  hypogastric  region.  In  these  circum- 
stances inspection  reveals  a  sulcus  or  depression  across  the 
epigastrium,  with  a  swelling  at  or  below  the  level  of  the  navel. 
The  degree  of  gastroptosis  varies  according  to  the  position  of 
the  pylorus,  being  comparatively  slight  when  adhesions  exist 
between  it  and  the  liver,  but  usually  very  pronounced  if  the 
tumour  is  not  attached  to  the  surrounding  viscera.  In  the 
latter  case  the  pylorus  becomes   dislocated  downwards   and  to 


PHYSICAL  SIGNS  147 

the  left  by  the  weight  of  the  enlarged  stomach,  and  in  two  of 
our  cases  was  found  after  death  to  be  adherent  to  the  uterus  in 
the  pelvis  (fig.  44). 

(c)  Visible  Peristalsis. — Under  normal  circumstances  the 
stomach  is  invisible ;  but  if  its  walls  are  thickened  from 
hypertrophy  of  its  muscular  coat,  and  the  abdominal  parietes 
are  attenuated,  each  contraction  of  the  viscus  can  be  seen  as 
an  undulating  swelling,  which  slowly  traverses  the  surface  of 
the  abdomen  from  left  to  right.  The  movements  occur 
spontaneously  and  in  rhythmic  sequence  after  every  meal,  and 
may  be  excited  at  any  time  by  rubbing  the  abdominal  wall  or 
by  the  application  of  ice  to  the  skin  of  the  epigastrium.  The 
frequency  and  force  of  these  contractions  vary  under  different 
conditions,  being  feeble  and  intermittent  when  the  stomach  is 
empty  or  its  tissues  abnormally  thin,  but  extremely  conspicuous 
and  practically  incessant  when  the  hypertrophied  organ  is 
endeavouring  to  force  its  contents  through  an  obstructed  pylorus. 
It  may  be  observed  that,  unlike  visible  peristalsis  of  the  colon, 
the  movements  of  the  stomach  are  not  accompanied  by  pain. 

(d)  Tumour. — In  addition  to  the  swelling  formed  by  an 
enlarged  and  dislocated  stomach,  the  morbid  growth  itself 
often  gives  rise  to  a  tumour  which  is  visible  to  the  naked 
eye.  This  is  especially  the  case  when  the  pylorus  is  the  seat 
of  the  disease,  but  a  large  neoplasm  of  the  inferior  curvature, 
of  the  anterior  wall,  or  of  the  omentum  may  be  also  easily 
detected.  On  the  other  hand,  growths  which  affect  the  lesser 
curvature  are  seldom  visible  except  on  deep  inspiration  or 
after  the  stomach  has  been  artificially  distended,  while  those 
that  occupy  the  cardia  are  effectually  hidden  beneath  the 
sternum  and  ribs. 

(e)  Enlarged  Veins. — Owing  to  the  pressure  it  exerts  upon 
the  inferior  vena  cava,  a  dilated  stomach  is  frequently  accom- 
panied by  enlargement  of  the  superficial  veins  of  the  abdomen. 
As  a  rule  the  condition  is  symmetrical  and  chiefly  affects  the 
superficial  epigastric  and  superficial  circumflex  iliac  veins, 
which  may  be  traced  upwards  along  the  sides  of  the  abdomen 
and  chest,  where  they  form  numerous  anastomoses  with  the 
branches  of  the  intercostal,  internal  mammary  and  superior 
epigastric  veins.  In  other  cases  all  the  superficial  venules  of 
the  lower  abdomen,  the  back  and  upper  parts  of  the  thighs 
are  uniformly  dilated. 

l2 


148  CANCEE  OF  THE   STOMACH 

(/)  Retraction  of  the  Navel  ensues  from  cancerous  infiltra- 
tion of  the  round  ligament  or  of  the  subperitoneal  tissue 
immediately  subjacent  to  it,  and  is,  consequently,  a  sign  of 
considerable  importance.  Occasionally  the  umbilicus  exhibits 
superficial  excoriation,  or  one  or  two  nodules  of  new  growth 
may  be  detected  in  the  subcutaneous  tissue  in  its  vicinity. 

EXAMINATION    OF    THE    STOMACH 

This  includes  the  investigation  of  the  size  and  capacity  of 
the  organ,  of  its  secretory  and  motor  functions,  and  of  the 
microscopical  characters  of  its  contents. 

Size  and  Position. — Tn  addition  to  the  general  informa- 
tion derived  from  inspection  it  is  necessary  to  have  recourse  to 
some  special  method  whereby  the  size  and  location  of  the 
viscus  may  be  accurately  determined.  Of  the  various  methods 
in  vogue,  only  those  of  auscultatory  percussion,  artificial  in- 
flation, and  electric  illumination  require  special  mention. 

Auscultatory  Percussion. — This  is  performed  in  the  follow- 
ing manner.  Half  a  pint  or  more  of  effervescent  soda-water  is 
administered  to  the  patient,  with  the  view  of  procuring 
moderate  distension  of  the  stomach,  and  he  is  then  directed 
to  lie  upon  his  back  with  the  shoulders  and  head  slightly 
raised.  The  examiner  places  the  end  of  a  stethoscope  over  the 
epigastrium,  and  then  makes  a  series  of  sharp  taps  with  the 
index  finger  of  the  right  hand  upon  the  abdominal  wall  along 
lines  which  radiate  from  the  point  of  auscultation.  As  long 
as  percussion  is  made  over  a  spot  where  the  stomach  is  in 
contact  with  the  parietes  of  the  abdomen  the  shock  conveyed 
to  the  ear  is  of  the  same  intensity ;  but  immediately  the 
finger  travels  off  the  gastric  area  the  sound  becomes  faint  and 
toneless.  The  points  at  which  this  change  takes  place  are 
marked  on  the  skin  with  a  blue  pencil,  and  the  investigation  is 
continued  in  all  directions  until  the  entire  outline  of  the 
viscus  is  mapped  out  on  the  skin.  This  method  is  not  only 
very  accurate  in  its  results,  but  is  also  easy  to  perform, 
and  does  not  entail  any  discomfort  to  the  patient.  The  only 
point  which  requires  special  attention  is  the  application  of  the 
stethoscope  immediately  over  the  stomach. 

Artificial  Inflation.- — This  may  be  performed  in  two  ways  : 
either   by  the    administration    of    chemical    substances  which 


PHYSICAL   SIGNS  149 

generate  gas  when  mixed  together,  or  by  forcibly  pumping  air 
into  the  organ.  Inflation  by  carbon  dioxide  is  a  very  old  pro- 
cedure (Wagner,  1869),  which  has  recently  been  again  brought 
into  fashion  by  Eiegel  and  Boas.  Forty  to  sixty  grains  of 
bicarbonate  of  sodium  and  thirty  to  forty  grains  of  tartaric 
acid  are  each  dissolved  in  about  eight  ounces  of  water  contained 
in  separate  glasses.  The  patient  first  drinks  the  acid,  and 
then  the  alkaline  solution,  and  is  directed  not  to  eructate  any 
gas.  The  interaction  of  the  two  substances  causes  a  rapid 
evolution  of  carbon  dioxide,  which  distends  the  stomach  to 
its  utmost  capacity  and  causes  its  outlines  to  become  visible 
upon  inspection  of  the  abdomen.  In  the  second  method  a 
soft  tube  is  introduced  into  the  stomach,  and  air  is  either 
pumped  in  by  a  hand  bellows  or  blown  in  by  the  mouth  until 
the  organ  is  sufficiently  distended  to  be  apparent.  Gaseous 
inflation  of  the  stomach,  although  often  a  valuable  aid  in 
diagnosis,  is  not  devoid  of  danger,  as  the  upward  displace- 
ment of  the  diaphragm  which  it  occasions  is  apt  to  embarrass 
the  action  of  the  heart  and  to  produce  syncope.  When  the 
pylorus  is  incompetent  and  the  walls  of  the  stomach  rigidly 
infiltrated,  the  gas  often  escapes  into  the  intestine  without 
producing  distension  of  the  viscus.  Hexameter  prefers  to 
use  a  rubber  bag  made  in  the  shape  of  the  stomach,  which  is 
introduced  at  the  end  of  a  soft  tube  and  can  be  inflated  in 
position.  By  allowing  the  air  to  escape  into  a  spirometer  the 
capacity  of  the  stomach  may  also  be  gauged. 

Trans-illumination  {Gastrodiaphany). — Einhorn  has  in- 
vented a  method  of  illuminating  the  stomach  by  means  of  a  small 
electric  lamp  fixed  in  the  eye  of  a  tube.  After  the  organ  has 
been  washed  out  the  patient  drinks  a  pint  of  water  and  the 
instrument  is  passed  into  the  stomach.  The  viscus  transmits 
the  light  through  the  abdominal  walls  and  becomes  visible 
as  a  red  zone.  According  to  our  experience  gastrodiaphany  is 
of  very  little  value,  although  it  is  highly  spoken  of  by  some 
American  writers. 

Exploration  with  a  Tube.— By  the  employment  of  a  soft 
tube  it  is  possible  to  determine  (1)  the  existence  of  an  obstruc- 
tion to  the  entry  of  food ;  (2)  the  motorial  activity  and  general 
capacity  of  the  stomach;  (3)  the  chemical  characters  and 
digestive  properties  of  the  gastric  secretion  ;  (4)  the  presence 
of  blood,  bile,  micro-organisms,  and  of  particles  of  new  growth. 


150  CANCEE  OF  THE   STOMACH 

(1)  Carcinoma  of  the  stomach  is  accompanied  by  pain  and 
difficulty  of  deglutition  whenever  the  disease  involves  the 
cardiac  orifice  or  extends  into  the  oesophagus.  In  such  cases 
the  employment  of  a  soft  tube  not  only  will  determine  the 
existence  and  site  of  the  obstruction,  but  will  often  afford 
valuable  information  concerning  the  condition  and  character 
of  the  growth.  In  order  to  obtain  the  best  results  the  tube 
should  be  of  moderate  size,  with  an  opening  about  one  inch 
from  its  point,  and  should  be  graduated  externally  in  inches 
or  centimetres.  The  instrument  is  gently  inserted  until  its 
progress  is  firmly  arrested,  when  the  scale  at  the  level  of  the 
incisor  teeth  is  read  off  and  recorded.  The  patient  is  then 
made  to  cough  several  times,  so  as  to  drive  any  material  that 
may  exist  above  the  stricture  into  the  interior  of  the  tube,  after 
which  the  free  extremity  is  firmly  closed  with  the  finger  and 
the  instrument  quickly  withdrawn.  Since  the  average  distance 
between  the  incisor  teeth  and  the  cardiac  orifice  in  an  adult 
man  is  16-18  inches  (40-47  cms.),  the  site  of  the  obstruction 
is  readily  determined  by  reference  to  the  scale  of  measurement ; 
but  it  must  always  be  borne  in  mind  that  a  stomach  which  is 
contracted  b}7  diffuse  cancerous  infiltration  may  also  prevent  the 
insertion  of  a  tube  beyond  eighteen  inches.  The  quantity  of 
material  extracted  varies,  according  to  the  severity  of  the 
stenosis,  from  one  drachm  to  two  fluid  ounces  or  more,  and 
usually  consists  of  milk  or  undigested  food  mixed  with  mucus 
and  saliva.  In  reaction  it  is  neutral  or  alkaline,  and  it 
exhibits  no  digestive  power  upon  egg  albumin  after  acidifi- 
cation with  hydrochloric  acid.  If  the  morbid  growth  is 
ulcerated  a  small  quantity  of  grurnous  matter  or  bright  blood 
may  be  present,  while  occasionally  the  material  possesses  a  dis- 
agreeable or  fetid  odour  indicative  of  sloughing  of  the  neoplasm. 
On  microscopical  examination  particles  of  food,  epithelial  cells, 
torulse,  cocci,  and  bacteria  can  always  be  detected,  and  in  some 
instances  blood  or  pus  cells  and  even  fragments  of  the  growth 
may  be  recognised. 

(2)  In  its  normal  state  the  stomach  in  the  early  morning 
either  is  empty  or  at  most  contains  only  one  or  two  cubic  centi- 
metres of  an  acid  mucoid  fluid,  while  its  motor  activity  is  suffi- 
cient to  dispose  of  a  full  meal  within  seven  hours.  Should  the 
pylorus  be  contracted,  however,  or  the  muscular  coat  of  the  organ 
be  too  feeble  to  perform  its  accustomed  functions,  the  food  will 


PHYSICAL  SIGNS  151 

remain  in  the  stoniach  for  a  nruck  longer  period.  It  is  there- 
fore advisable  in  every  case  to  conduct  the  first  investigation  in 
the  early  morning,  when  no  food  has  been  taken  for  at  least 
twelve  hours.  As  soon  as  the  instrument  has  been  inserted 
into  the  stomach  the  patient  is  made  to  compress  the  abdomen 
with  his  hands  and  to  cough  vigorously,  when  the  rise  of  intra- 
gastric pressure  causes  the  evacuation  of  any  material  the 
organ  may  contain.  Should  these  measures  fail  to  procure  the 
desired  result,  the  nozzle  of  a  glass  syringe  may  be  attached 
to  the  end  of  the  tube  and  siphonage  started  by  means  of 
suction.  In  every  case  of  gastric  cancer  accompanied  by  en- 
feeblement  of  the  muscular  coat  of  the  organ  a  certain  amount 
of  undigested  food  may  be  extracted  in  this  manner,  while  in 
pyloric  obstruction  the  quantity  sometimes  exceeds  two  pints. 
The  phenomenon  of  food  stagnation  which  is  thus  demon- 
strated not  only  establishes  the  existence  of  gastrectasis,  but 
constitutes  a  rough  indication  of  the  degree  of  dilatation  of  the 
stoniach.  This  conclusion  may  be  further  confirmed  by  the 
detection  of  some  article  of  diet,  such  as  beans,  peas,  grape- 
stones,  or  other  vegetable  matter,  which  had  been  eaten  by  the 
patient  several  days,  or  even  wTeeks,  previously. 

(3)  In  order  to  obtain  the  most  reliable  information  con- 
cerning the  state  of  the  gastric  secretion,  it  is  necessary  to 
examine  the  contents  of  the  viscus  at  the  height  of  digestion 
rather  than  during  the  period  of  food  stagnation.  For  this 
purpose  the  organ  is  washed  out  in  the  early  morning,  and 
afterwards  the  patient  partakes  of  a  test  meal  composed  of  half 
a  pint  of  weak  tea  and  a  thick  slice  of  bread  and  butter.  At 
the  end  of  an  hour  the  tube  is  again  passed  and  the  semi- 
digested  material  extracted.  It  may  usually  be  observed  that 
the  quantity  of  liquid  obtained  in  this  manner  equals  or  even 
exceeds  the  amount  administered,  and  that  the  bread  shows 
little  or  no  signs  of  digestion.  There  is  also  a  large  excess  of 
mucus,  which  renders  filtration  through  paper  such  a  tardy 
process  that  it  is  generally  advisable  to  strain  through  well- 
washed  butter-muslin.  In  almost  every  instance  the  filtrate  is 
acid  in  reaction,  although  when  triturated  with  the  clecinormal 
solution  of  soda  its  total  acidity  is  found  to  be  much  reduced. 

Free  Hydrochloric  Acid. — The  first  investigations  upon 
this  subject  were  conducted  by  Golding  Bird  in  1842,  who 
summed  up  a  series  of  most  admirable  researches  by  the  state- 


152  CANCEE  OF  THE   STOMACH 

ment  that  '  the  matter  brought  up  (i.e.  vomited)  contains  con- 
siderable quantities  of  free  hydrochloric  acid  during  the  more 
irritative  stage  of  the  disease,  which  gradually  decreases  in  pro- 
portion to  the  decrease  in  strength,  while  the  organic  acids 
increase  in  proportion  to  the  decrease  of  free  hydrochloric  acid.' 
The  complicated  method  of  anal}Tsis  employed  by  Golding  Bird 
was  probably  responsible  in  great  measure  for  the  neglect  with 
which  the  subject  was  treated,  for  it  was  not  until  1879,  when 
v.  den  Velden  published  his  observations  upon  the  absence  of 
hydrochloric  acid  in  cancer  of  the  pylorus,  that  the  profession 
realised  the  important  bearing  of  the  discovery  upon  diagnosis. 
Immediately  this  essay  appeared  the  subject  was  ardently  taken 
up  by  Riegel,  Ewald,  Huebner,  Honigmann,  Thiersch,  Jaworski 
and  Gluczynski,  Kahn  and  v.  Mering,  Bosenbach  and  others, 
who  not  only  confirmed  the  general  statements  of  v.  den  Velden, 
but  went  so  far  as  to  declare  that  an  absence  of  free  hydro- 
chloric acid  constituted  an  almost  infallible  sign  of  carcinoma  of 
the  stomach.  Like  most  other  scientific  conclusions  that  are 
formulated  in  haste,  this  one  was  duly  repented  of  at  leisure, 
for  it  was  soon  shown  not  only  that  certain  cases  are  accom- 
panied by  the  free  acid  throughout  their  entire  course,  but  that 
other  diseases  occasionally  exhibit  a  similar  diminution  of  the 
acid  secretion.  Thus  Ewald,  Kahn  and  v.  Mering,  Steinon, 
Eosenheim,  Bouveret,  "Waetzoldt,  and  other  observers  have 
recorded  examples  of  gastric  cancer  in  which  the  free  acid  not 
only  persisted,  but  was  present  in  excess  ;  while  its  total  disap- 
pearance has  been  observed  in  atrophic  gastritis,  achylia  gastrica, 
lardaceous  degeneration  of  the  stomach,  certain  infectious  fevers 
(Wolfram),  Addison's  disease  (Kohler),  pernicious  anaemia, 
Bright's  disease,  and  many  cases  of  phthisis  (Rosenthal,  Fen- 
wick).  VTe  find  that  out  of  a  total  of  495  cases  of  gastric 
carcinoma,  published  by  various  authorities,  where  the  contents 
of  the  stomach  were  carefully  and  systematically  examined, 
free  hydrochloric  acid  was  absent  in  89  per  cent.,  and  present  in 
small  quantities  or  at  irregular  intervals  in  9"7  per  cent.,  while 
in  1-3  per  cent,  it  existed  in  excess.  This  conclusion  tallies 
very  closely  with  our  own  observations,  which  indicate  that  the 
colour  tests  for  free  hydrochloric  acid  give  a  negative  reaction  in 
91  per  cent,  of  all  cases  of  the  complaint. 

Numerous  tests  have  been  proposed  for   the    detection  of 
free  hydrochloric  acid,  but  only  two  need  be  described. 


PHYSICAL  SIGNS  153 

(1)  Dimetlujl-amido-azo-benzol  was  introduced  by  Topfer 
on  account  of  its  delicacy  and  ease  of  application.  In  the 
form  of  a  '5  per  cent,  solution  in  alcohol  it  possesses  a 
golden-yellow  colour,  which  instantly  changes  to  cherry-red 
when  brought  into  contact  with  the  free  acid.  This  reaction 
is  readily  observed  by  allowing  a  drop  of  the  contents  of  the 
stomach  to  mingle  with  a  small  quantity  of  the  solution  upon 
a  porcelain  dish,  when  the  characteristic  colour  is  seen  to 
develop  at  the  junction  of  the  two  fluids. 

(2)  Phloroglucin  and  vanillin  dissolved  in  alcohol  was  first 
recommended  by  Giinzberg  as  a  convenient  test  for  the  presence 
of  the  free  mineral  acid,  and  has  attained  a  world-wide  popu- 
larity. In  order  to  obtain  the  best  results  two  grammes  of 
phloroglucin  and  one  gramme  of  vanillin  are  dissolved  in  100 
grammes  of  absolute  alcohol,  and  the  solution  is  preserved 
in  a  black  well-stoppered  bottle,  as  it  is  soon  decomposed 
if  exposed  to  the  light  (Boas).  A  few  drops  are  mixed  in  a 
white  china  dish  with  an  equal  quantity  of  the  filtered  gastric 
contents,  and  gently  warmed  over  a  spirit  lamp.  If  free  hydro- 
chloric acid  is  present,  a  beautiful  rose  colour  will  develop  at 
the  spot  where  the  mixture  dries.  If  too  much  heat  is 
applied,  a  brownish-red  tint  is  produced,  even  in  the  absence  of 
the  acid. 

The  diminished  quantity  of  hydrochloric  acid  in  carcinoma 
of  the  stomach  was  originally  attributed  by  Biegel  to  its 
neutralisation  by  the  alkaline  secretions  of  the  morbid  growth, 
while  according  to  Ewald  the  phenomenon  was  depen- 
dent upon  failure  of  the  general  nutrition.  These  theories, 
however,  were  easily  disproved,  and  it  is  now  known  that  the 
failure  of  the  secretion  depends  upon  secondary  inflamma- 
tion and  atrophy  of  the  gastric  glands.  Thus  Mathieu  and 
Kosenheim  have  shown  that  in  every  case  where  free  acid  is 
absent  during  life  the  stomach  presents  signs  of  chronic 
inflammation,  with  a  disappearance  of  the  parietal  cells  and 
sometimes  atrophy  of  the  entire  gland.  This  condition  is  a 
permanent  one,  since  the  acid  does  not  reappear  even  after 
removal  of  the  growth  (Mintz). 

These  facts  serve  to  explain  the  more  uniform  absence 
of  free  acid  when  the  pylorus  is  involved  than  in  those 
cases  where  the  tumour  is  comparatively  circumscribed  and 
affects  the  walls  or  curvatures  of  the  stomach,  for  it  has  already 


154  CANCER  OF  THE   STOMACH 

been  shown  that  chronic  gastritis  is  usually  due  to  retention  of 
the  food  and  irritation  of  the  gastric  mucous  membrane  by  the 
acid  products  of  fermentation. 

The  continued  existence  of  free  acid  along  with  carcinoma 
is  chiefly  met  with  under  two  conditions  :  (1)  A  small  growth 
situated  upon  a  wall  of  the  stomach,  (2)  cancerous  invasion  of 
a  simple  chronic  ulcer  or  its  scar.  In  the  former  case  the 
disease  is  more  or  less  circumscribed,  gastrectasis  is  slight, 
and,  with  the  exception  of  that  in  the  immediate  vicinity  of  the 
tumour,  the  mucous  membrane  of  the  stomach  is  practically 
free  from  inflammation.  In  the  latter  condition  hyper- secretion 
has  usually  existed  for  a  considerable  period  of  time,  and  the 
signs  of  it  do  not  disappear  until  the  morbid  growth  has  given 
rise  to  a  diffuse  gastritis. 

It  is  never  sufficient  to  rely  upon  an  absence  of  the  acid 
in  a  single  examination,  but  in  every  case  the  investigation 
should  be  repeated  under  similar  conditions  at  least  three 
times.  This  is  especially  important  when  the  first  attempt 
has  been  made  without  antecedent  lavage  or  the  administra- 
tion of  a  test  meal,  for  we  have  more  than  once  noted  a  reap- 
pearance of  the  free  acid  after  the  stomach  had  been  thoroughly 
cleansed  for  a  few  days  and  the  patient  fed  by  rectal  injections. 
When  these  several  precautions  are  adopted  the  continued 
absence  of  free  hydrochloric  acid  constitutes  valuable  confirma- 
tory evidence  of  the  existence  of  a  morbid  growth. 

The  secretion  of  hydrochloric  acid  is  seldom  entirely 
abolished,  since  it  can  usually  be  detected  in  a  combined  state 
by  means  of  appropriate  tests  ;  while  according  to  Schule  the 
determination  of  the  total  deficit  is  of  much  importance  in  the 
differential  diagnosis  of  carcinoma  and  benign  affections  of 
the  pylorus.  Inasmuch,  however,  as  the  total  amount  of  acid 
is  often  greatly  reduced  in  atrophic  gastritis  and  other  diseases 
of  the  stomach,  the  value  of  the  information  obtained  from  a 
quantitative  estimation  is  rarely  commensurate  with  the  labour 
expended  upon  it. 

Lactic  Acid. — It  was  formerly  the  custom  among  German 
writers  to  describe  a  stage  of  normal  digestion  which  was 
characterised  by  the  production  of  lactic  acid.  The  experi- 
ments upon  which  this  view  was  founded  appear,  however,  to 
have  been  falsified  by  the  accidental  introduction  of  lactic  acid 
with  the  bread  of  the  test  meal,  and  consequently  the  elaborate 


PHYSICAL   SIGNS  155 

theories  that  were  formulated  to  explain  the  development  of 
the  organic  acid  have  ceased  to  be  either  useful  or  interesting. 
Boas  was  the  first  to  call  attention  to  the  existence  of  an  excess 
of  lactic  acid  in  stomachs  affected  by  cancer,  and  subsequent 
investigations  have  confirmed  his  statement  upon  this  point. 
Like  the  absence  of  free  hydrochloric  acid,  the  presence  of 
lactic  acid  is  by  no  means  invariable,  and  it  is  interesting  to 
observe  that  in  those  exceptional  cases  where  the  free  mineral 
acid  is  present  the  organic  acid  is  usually  absent.  Among  109 
cases  collected  by  Schiff  in  which  lactic  acid  was  found  during 
the  period  of  digestion,  the  stomach  was  affected  with  carcinoma 
in  ninety-two,  or  84 "4  per  cent. ;  while  among  268  cases  of 
malignant  disease  of  the  organ,  lactic  acid  was  shown  to  exist 
in  197,  or  73*5  per  cent.  Strauss  noted  its  presence  in  91  per 
cent.,  Rosenheim  in  78  per  cent.,  Lindner  and  Kuttner  in  60  per 
cent.,  Hemmeter  in  82  per  cent.,  and  Osier  and  McCrae  in  75*3 
per  cent,  of  the  cases  they  examined.  According  to  our  experience? 
it  is  present  in  about  91  per  cent,  of  the  cases  where  the  pylorus 
is  the  seat  of  the  disease,  and  in  57  per  cent,  of  those  in  which 
the  growth  affects  the  cardia  or  a  circumscribed  area  of  the  organ. 

The  conditions  which  bring  about  an  excessive  formation  of 
lactic  acid  in  the  stomach  are :  (1)  Stagnation  of  the  food  ; 
(2)  a  deficiency  of  hydrochloric  acid ;  (3)  a  diminished  power 
of  digestion  and  absorption  of  proteids.  In  cases  of  gastric 
cancer,  and  especially  in  those  where  there  is  stenosis  of  the 
pylorus,  all  these  conditions  are  present,  and  consequently  malig- 
nant disease  is  more  often  associated  with  lactic  acid  fermen- 
tation than  any  other  affection.  It  is  important  to  remember, 
however,  that  the  same  requirements  are  sometimes  fulfilled 
by  other  lesions  than  carcinoma  of  the  stomach,  such,  for 
example,  as  benign  stenosis  of  the  pylorus  accompanied  by 
atrophic  gastritis,  or  partial  occlusion  of  the  lower  duodenum 
by  a  malignant  growth  or  the  pressure  of  a  tumour.  While, 
therefore,  the  discovery  of  lactic  acid  in  the  gastric  con- 
tents cannot  be  considered  as  pathognomonic  of  carcinoma  of 
the  stomach,  its  existence  along  with  other  symptoms  and  signs 
of  the  complaint  must  be  regarded  as  confirmatory  evidence  of 
the  disease. 

Many  elaborate  processes  have  been  invented  by  which 
lactic  acid  may  be  detected  and  its  quantity  estimated,  but 
their  value  as  an  aid  to  diagnosis  is  extremely  doubtful.      All 


156  CANCEE  OF  THE   STOMACH 

that  is  required  is  some  method,  easy  of  application,  by  means 
of  which  the  substance  can  be  recognised  when  present  in 
excess.  This  simple  qualification  is  amply  fulfilled  by  the  test 
proposed  by  Ueffelmann,  which  consists  in  mixing  10  c.c.  of  a 
4  per  cent,  solution  of  carbolic  acid  with  20  c.c.  of  water 
containing  one  drop  of  a  strong  solution  of  perchloride  of  iron. 
The  mixture  presents  an  amethyst-blue  colour,  which  changes 
to  canary-yellow  on  the  adddition  of  lactic  acid.  The  delicacy 
of  the  reaction  is  destroyed  by  the  presence  of  free  hydrochloric 
acid,  and  a  somewhat  similar  colouration  is  produced  by  glucose, 
phosphates,  and  alcohol.  Tf  any  doubt  exists  as  to  the  result  of 
the  test,  a  small  quantity  of  the  filtered  gastric  fluid  should  be 
thoroughly  shaken  with  ten  times  its  volume  of  pure  ether, 
and  allowed  to  stand  until  the  fluids  separate  from  one  another. 
The  ethereal  portion  of  the  mixture  is  then  siphoned  off  and 
gently  evaporated,  and  the  residue  is  dissolved  in  distilled  water 
and  tested  for  lactic  acid  as  in  the  previous  case. 

In  rare  instances  the  contents  of  the  stomach  extracted  one 
hour  after  a  test  meal  are  found  to  be  neutral  or  alkaline,  and 
to  contain  neither  lactic  nor  hydrochloric  acid.  This  absence  of 
acidity  neither  supports  nor  negatives  the  existence  of  carcinoma. 

Secretion  of  Pepsin  and  Rennet. — The  digestive  power  of 
the  gastric  juice  is  always  greatly  impaired  by  a  deficiency 
of  hydrochloric  acid,  although  it  is  now  accepted  that,  so  long 
as  the  stomach  is  able  to  absorb  peptones,  a  combination  of 
pepsin  and  lactic  acid  is  sufficient  for  the  digestion  of  proteids. 
In  every  case  the  filtered  contents  of  the  stomach,  when  acidu- 
lated with  hydrochloric  acid,  exhibit  marked  digestive  pro- 
perties, and  if  lavage  is  performed  with  a  0'2  per  cent,  solution 
of  the  mineral  acid  the  resultant  fluid  will  readily  dissolve  egg 
albumin  at  the  temperature  of  the  body.  Although  the  results 
have  no  particular  value  from  a  clinical  standpoint,  the  quantity 
of  pepsin  secreted  by  the  stomach  may  be  determined  by  the 
following  method,  devised  by  Hammerslag :  10  c.c.  of  a  1  per 
cent,  solution  of  egg  albumin,  containing  free  hydrochloric  acid 
to  the  amount  of  0-4  per  cent.,  aro  placed  in  an  Esbach  albu- 
minometer,  and  to  them  are  added  5  c.c.  of  the  gastric  filtrate  to 
be  examined.  A  second  albuminometer  is  filled  with  10  c.c.  of  the 
standard  solution  of  egg  albumin  and  hydrochloric  acid,  and  both 
tubes  are  allowed  to  remain  in  an  incubator  at  a  temperature  of 
98°  F .  for  an  hour.    At  the  end  of  this  time  the  amount  of  albumin 


PHYSICAL   SIGNS  157 

in  each  is  determined  by  the  Esbach  reagent,  when  the  activity  of 
the  pepsin  in  the  gastric  nitrate  may  be  roughly  gauged  by 
observing  the  difference  in  the  amount  of  precipitated  albumin 
in  the  two  tubes. 

According  to  Boas,  the  rennet  ferment  usually  persists  after 
the  disappearance  of  hydrochloric  acid,  but  this  fact  has  little 
clinical  significance.  Its  existence  in  the  gastric  contents  may 
be  determined  by  neutralising  5  c.c.  of  the  latter  with  carbonate 
of  sodium  and  adding  an  equal  quantity  of  milk.  After  stand- 
ing for  fifteen  minutes  in  a  warm  place  a  firm  coagulum  of 
casein  will  be  found  to  have  formed  if  rennet  was  present  in  the 
gastric  fluid. 

Microscopical  Examination  of  the  Contents  of  the  Stomach. 
Micro-organisms. — In  addition  to  various  kinds  of  undigested 
food,  vast  quantities  of  torulse  and  other  fungi  may  usually  be 
observed  in  the  residue  upon  the  filter.  It  was  formerly 
believed  that  the  presence  of  sarcinse  was  indicative  of  cancer 
of  the  pylorus ;  but  it  is  now  known  that,  far  from  being  patho- 
gnomonic of  the  complaint,  they  occur  quite  as  often  in  cases  of 
benign  stenosis  as  in  malignant  disease.  Of  greater  importance 
are  the  so-called  Oppler-Boas  bacilli.  These  are  long,  rod- 
shaped,  non-motile  organisms,  which  are  often  thicker  at  one 
end  than  the  other,  and  can  easily  be  recognised  in  stained 
cover-slip  preparations.  Like  many  other  fungi  met  with  in 
the  stomach,  they  excite  lactic  acid  fermentation  of  carbo- 
hydrates, and  consequently  often  exist  in  enormous  numbers  when 
the  organ  is  affected  by  a  neoplasm.  They  were  observed  in 
nearly  90  per  cent,  of  the  cases  of  gastric  cancer  examined  by 
Oppler,  Kauffmann  and  Schlesinger,  Biegel,  and  Hemmeter  and 
Adler. 

Fragments  of  Tumour  and  Cancer  Cells.  —  It  has  already 
been  remarked  that  during  the  process  of  disintegration  frag- 
ments of  the  growth  are  apt  to  become  detached,  and  may  be 
occasionally  recognised  in  the  vomit.  Several  cases  have  come 
under  our  own  observation  where  the  discovery  of  pieces  of  new 
growth  in  the  ejecta  served  to  confirm  the  diagnosis  ;  and 
Mathieu  has  recently  observed  one  in  which  three  pieces  of 
epitheliomatous  tissue  were  eliminated  in  the  vomit  In  most 
of  these  cases,  however,  the  tumour  has  already  reached  a 
considerable  size  and  is  accompanied  by  such  pronounced 
symptoms  that  its  recognition  is  not  attended  by  any  difficulty. 


158 


CANCER  OF  THE   STOMACH 


On  the  other  hand,  there  is  reason  to  believe  that  even  at  an 
early  period  of  the  complaint  minute  conglomerations  of  cells, 
strips  of  mucous  membrane  from  the  vicinity  of  the  growth,  or 
isolated  cells  showing  atypical  mitoses,  are  often  spontaneously 
detached,  and  may  be  recognised  by  a  systematic  examination 
of  the  gastric  contents. 

(a)  Microscopic  aggregations  of  cancer  cells  have  been 
described  by  many  writers,  but  they  are  not  always  easy  to 
recognise,  on  account  of  the  similarity  that  exists  between  them 


Fig.  35. — Drawing  of  a  small  mass  of  carcinomatous  tissue 
expelled  from  the  stomach.     (Ewald.) 


and  the  particles  of  epithelium  that  are  habitually  shed  in  cases 
of  chronic  gastritis.  When,  however,  the  cells  present  the 
appearance  of  concentric  cell-nests,  they  constitute  strong 
evidence  of  the  existence  of  a  neoplasm. 

(b)  In  order  to  obtain  shreds  of  mucous  membrane  or 
isolated  cells  from  the  stomach,  certain  precautions  have  to  be 
taken.  In  the  first  place,  the  stomach  should  be  empty  at  the 
time  of  the  examination,  since  the  presence  of  undigested  food 
constitutes  a  formidable   obstacle  to  their  recognition.     The 


PHYSICAL  SIGNS  159 

viscus  should,  therefore,  be  carefully  washed  out  in  the  even- 
ing, and  no  food  be  permitted  until  after  lavage  on  the  following 
morning ;  while  in  some  cases  it  may  be  necessary  to  perform 
the   preliminary    cleansing    several    times    and    to    feed   the 


Fig.  36. — Fragment  of  gastric  mucosa  obtained  by  curettage,  showing  the  lumen 
of  two  gland  tubules.  The  interglandular  connective  tissue  is  thickened 
and  permeated  with  small  round-celled  filtration.  The  greater  portion 
of  the  epithelium  of  the  gland  is  detached ;  many  cells  show  vacuoles, 
some  of  them  so  large  as  to  submerge  the  identity  of  the  original  cell, 
which  appears  either  as  a  small  rim  of  protoplasm  around  a  vacuole  or 
as  a  smaller  mass  at  the  side  of  a  huge  vacuole.  Numerous  gland  cells  are 
in  the  state  of  atypical  mitosis.  There  are  in  both  asymmetrical  mitoses, 
some  with  disrupted  chromosomes.  In  the  centre  of  one  lumen  is  a 
four-lobed  cell  presenting  four  nuclei.  Asymmetrical  mitoses  do  not 
derive  their  name  from  asymmetry  in  shape  or  configuration ;  an 
asymmetrical  mitosis  is  one  whose  daughter-stars  do  not  contain  a  like 
or  even  number  of  chromosomes.     (Hemmeter.) 


patient  by  the  rectum  for  two  or  three  clays.  As  a  rule  a 
soft  tube  of  medium  calibre  is  sufficient  for  all  purposes  ;  but 
Hemmeter  prefers  one  in  which  the  terminal  orifice  is  provided 
with  sharp  edges   which  can  scrape  or  '  curette '  the  gastric 


160  CANCER   OF  THE   STOMACH 

mucosa.  About  half  a  pint  of  warm  normal  saline  solution  is 
poured  into  the  viscus  through  the  tube,  which  is  then  alter- 
nately inserted  to  its  full  extent  and  partially  withdrawn  until 
its  point  has  been  brought  into  contact  with  the  greater  part 
of  the  mucous  membrane.  A  second  half -pint  of  saline  solu- 
tion is  then  introduced,  after  which  the  whole  is  rapidly 
siphoned  off  into  a  conical  glass  and  allowed  to  stand  for  two 
or  three  hours.  The  sediment  is  then  placed  in  a  centrifugal 
machine  and  the  ultimate  deposit  stained  and  examined  b}r 
the  microscope. 

Shreds  of  mucous  membrane  may  be  obtained  in  this 
manner  in  most  cases  of  subacute  and  chronic  gastritis  ;  but 
those  which  are  met  with  in  gastric  cancer  are  stated  to  present 
two  characteristic  features  :  the  peptic  ducts  are  much  elongated 
and  dilated,  and  are  separated  from  one  another  by  an  excess 
of  connective  tissue ;  while  their  cells  are  either  partially  or 
completely  detached  from  the  basement  membrane,  and  exhibit 
karyokinetic  figures  of  an  asymmetrical  form  (figs.  37  and  38). 

(c)  Although  atypical  mitoses  are  common  to  all  tissues 
which  are  undergoing  rapid  proliferation,  their  presence  in  cells 
derived  from  the  stomach  must  be  regarded  as  highly  sugges- 
tive of  a  neoplasm.  Bieder  seems  to  have  been  the  first  to 
diagnose  malignant  disease  of  the  peritoneum  from  the  presence 
of  a  large  number  of  cells  displa3ring  indirect  division  in  the 
fluid  withdrawn  from  the  abdomen,  and  Dock  was  able  to 
recognise  cancer  of  the  pleura  and  peritoneum  in  a  similar 
manner.  The  cells  present  in  the  serous  exudations  in  such 
cases  were  of  various  shapes  and  sizes,  and  frequently  contained 
vacuoles  large  enough  to  displace  or  obscure  the  nucleus. 
Hemmeter,  who  has  paid  much  attention  to  this  subject, 
states  that  the  forms  of  cell  and  nuclear  division  known  as  the 
equatorial  plate  and  the  monaster  are  frequently  observed 
in  the  gastric  cells  obtained  by  lavage,  and  has  published  some 
diagrams  (37  and  38)  showing  the  various  atypical  mitoses  that 
are  encountered. 

Palpation. — Palpation  of  the  abdomen  is  a  method  of 
examination  of  the  utmost  importance.  It  should  be  per- 
formed, in  the  first  instance,  while  the  patient  lies  upon  his 
back  with  his  shoulders  and  head  slightly  raised  and  his  knees 
bent  over  a  pillow.  The  examiner  stands  or  kneels  on  the 
right  side  of  the  couch,  and  gently  and  evenly  slides  his  hand 


PHYSICAL  SIGNS 


161 


from  one  part  or  the  abdomen  to  another,  without  exercising 
any  sudden  or  undue  pressure  with  the  fingers,  which  is  apt  to 


Fig.  37 


Fig.  38 

37  gives  a  number  of  cells  in  the  state  of  atypical  mitoses,  taken  from 
parts  of  the  specimen  illustrated  in  fig.  36.  To  the  left  side,  below  the 
centre,  is  a  mitotic  form  showing  a  cell  with  a  huge  vacuole  and  three 
nuclei;  directly  opposite,  on  the  right  side  of  the  illustration,  is  a  similar 
smaller  cell  in  which  the  protoplasm  has  surrounded  a  vacuole  like  a 
narrow  ring.  The  lowest  cell  in  the  figure  is  an  asymmetric  mitosis, 
showing  an  uneven  number  of  chromosomes  and  disrupted  chromosomes. 
This  is  also  shown  in  other  cells  of  fig.  38,  particularly  in  the  cells  show- 
ing a  crippled  pithode  stage.  The  cells  thus  pictured  were  discovered 
lying  detached  in  the  lumen  of  the  gland-ducts  as  shown  in  fig.  36. 
(Hemmeter.) 

M 


162  CANCEE  OP  THE   STOMACH 

induce  reflex  contraction  of  the  recti  muscles  of  the  abdomen. 
For  a  similar  reason  care  must  be  taken  that  the  hand  is  warm 
before  it  is  applied  to  the  skin.  The  patient  ought  not  to  be 
permitted  to  talk,  unless  it  is  necessary  to  distract  his  atten- 
tion, and  he  should  be  directed  to  breathe  easily  and  deeply,  so  as 
to  maintain  the  stomach  in  constant  movement.  Each  region 
is  explored  in  turn,  and  if  any  difficulty  is  encountered  in  the 
palpation  of  the  deep  structures,  the  patient  should  be 
made  to  recline  upon  his  left  side  with  the  head  bent  forwards, 
the  knees  drawn  up,  and  the  back  resting  against  the  left  knee 
of  the  examiner.  Sometimes  it  may  be  necessary  to  adopt  the 
knee-elbow  position.  The  points  to  which  particular  atten- 
tion is  directed  are :  (1)  The  existence  of  localised  tenderness  ; 
(2)  thickening  of  the  linea  alba  and  secondary  deposits  in  the 
skin ;   (3)  an  abdominal  tumour. 

(1)  Local  Tenderness. — This  is  much  less  characteristic 
than  in  cases  of  simple  ulcer.  It  chiefly  exists  over  the 
site  of  the  growth,  and  is  especially  noticeable  when  the 
disease  has  infected  the  omentum  or  some  other  neighbour- 
ing structure.  As  a  rule,  a  rapidly  growing  tumour  of  the 
body  of  the  stomach  is  more  tender  than  a  circumscribed 
scirrhus  of  the  pylorus,  and  not  infrequently  the  maximum 
pain  is  felt  at  some  little  distance  from  the  centre  of  the  mass, 
where  the  neoplasm  is  invading  fresh  tissue  or  has  undergone 
ulceration.  General  tenderness  over  the  region  of  the  stomach 
may  be  observed  in  cases  of  pyloric  stenosis  where  the  viscus  is 
inflamed  and  filled  with  gas,  and  in  most  of  those  in  which  the 
organ  is  affected  by  diffuse  cancerous  infiltration.  Manipulation 
of  a  tumour  is  often  followed  by  severe  pain,  which  persists 
for  several  hours  and  is  sometimes  accompanied  by  vomiting. 

Some  writers  have  asserted  that  the  pain  of  gastric  cancer 
is  often  referred  to  certain  areas  of  the  skin  which  present  an 
extreme  degree  of  hypersesthesia.  According  to  Head,  the 
stomach  receives  its  sensory  nerve-supply  from  the  sixth, 
seventh,  eighth,  and  ninth  dorsal  segments,  the  two  former 
supplying  the  cardia  and  the  last-named  the  pylorus  ;  con- 
sequently, in  cases  of  organic  disease  of  the  viscus  cutaneous 
tenderness  should  exist  in  front  from  the  level  of  the  nipple  to 
the  umbilicus,  and  posteriorly  from  the  fifth  to  the  twelfth 
dorsal  spine.  Each  area  is  also  supposed  to  present  certain 
specially  tender  points,  those  for  the  sixth  dorsal  area  being 


PHYSICAL   SIGNS  163 

just  below  the  nipple  and  at  the  angle  of  the  scapula  ;  those 
for  the  seventh  near  the  tip  of  the  ensiform  cartilage  and  below 
the  angle  of  the  scapula  ;  while  for  the  eighth  and  ninth  they 
are  situated  anteriorly  in  the  nipple  line  and  posteriorly  below 
the  inferior  angle  of  the  scapula.  The  same  observer  states 
that  there  are  painful  and  tender  areas  upon  the  scalp  which 
correspond  to  the  dorsal  cutaneous  areas,  the  occipital  region 
corresponding  to  the  tenth  dorsal  and  the  parietal  to  the  ninth. 
If  these  facts  were  correct  they  would  obviously  constitute  a 
very  valuable  aid  not  only  in  the  diagnosis  of  gastric  disease 
generally,  but  in  the  exact  location  of  an  ulcer  or  a  growth.  Un- 
fortunately, the  results  of  clinical  experience  do  not  confirm  the 
supposititious  value  of  these  statements,  for  although  we  have 
carefully  examined  several  hundred  cases  of  gastric  disease,  we 
have  never  been  able  to  demonstrate  either  that  cutaneous 
hyperesthesia  is  a  constant  accompaniment  of  an  ulcer  or  a 
growth,  or  that  its  situation  corresponds  in  any  way  with  the 
location  of  the  lesion  in  the  stomach.  The  only  affection 
which,  in  our  experience,  is  frequently  associated  with  tender 
areas  in  the  regions  mentioned  is  subacute  gastritis  with 
flatulent  distension  of  the  stomach  or  colon,  and  even  in  this 
disorder  they  vary  greatly  in  position  at  different  periods  of  the 
day.  As  an  indication  of  gastric  carcinoma  we  regard  super- 
ficial tenderness  as  not  only  valueless  but  absolutely  misleading. 
(2)  Metastases  in  the  Abdominal  Wall. — The  occasional 
development  of  secondary  deposits  in  the  skin  of  the  abdomen 
has  long  been  recognised,  although  their  importance  has  not 
been  sufficiently  appreciated.  They  may  occur  in  the  form 
either  of  an  induration  of  the  linea  alba  (Catteau,  Villar,  Legg), 
or  of  small  rounded  tumours  situated  in  the  subcutaneous 
tissue.  The  former  condition  is  detected  upon  palpation  as  a 
hard  fixed  and  cord-like  thickening,  which  extends  from  the 
ensiform  cartilage  to  the  navel  and  occasionally  reaches  thence 
to  the  pubes.  When  the  round  ligament  is  infiltrated  by  the 
new  growth  the  umbilicus  is  usually  retracted,  the  skin  around 
it  is  adherent,  and  its  surface  is  uneven,  red,  or  excoriated ; 
but  in  those  cases  where  the  median  induration  is  due  to 
cancerous  invasion  of  the  linea  alba  and  of  the  subjacent 
connective  tissue  the  navel  often  remains  unaffected.  In 
the  former  case  the  peritoneum  usually  exhibits  secondary 
growths,  and  the  linear  thickening  only  extends  as  far  as  the 

M    2 


164  CANCEE  OF  THE   STOMACH 

umbilicus,  but  in  the  latter  the  serous  membrane  may  be  quite 
free  from  disease.  In  many  thin  but  healthy  persons  a  some- 
what similar  cord  can  be  felt,  owing  to  the  abnormal  size  of 
the  fetal  remains  which  exist  in  the  central  line  of  the  abdomen, 
but  it  never  extends  the  entire  distance  from  the  ensiform 
cartilage  to  the  symphysis  pubis. 

Superficial  Metastases  are  met  with  in  about  2*3  per  cent, 
of  all  cases  of  gastric  carcinoma.  They  are  usually  situated 
at  or  near  the  umbilicus,  where  they  form  small  hard  rounded 
tumours,  which  in  the  course  of  development  tend  to  become 
adherent  to  the  skin  and  occasionally  ulcerate.  Less  frequently 
several  discrete  nodules  appear  in  the  subcutaneous  tissue  near 
the  median  line,  or  in  the  linea  semilunaris,  which  consist  of 
minute  omental  hernise  that  have  become  infected  by  the  new 
growth.  Finally,  in  rare  instances  the  whole  of  the  abdomen, 
chest,  and  back  is  beset  with  small  movable  subcutaneous 
tumours,  which  vary  from  the  size  of  a  millet-seed  to  that  of  a 
pea,  and  exhibit  a  rapid  increase  of  size ;  even  the  muscles  may 
be  affected  (Merklen).  In  one  case  of  this  kind  that  came 
under  our  notice  more  than  three  hundred  nodules  were 
scattered  over  the  trunk ;  and  in  a  similar  instance  recorded  by 
Finlay  the  diagnosis  of  cylinder-celled  cancer  of  the  stomach 
was  made  from  the  microscopic  appearances  presented  by  one 
of  the  tumours  after  its  excision. 

(3)  Abdominal  Tumour. — Tumours  of  the  stomach  vary  so 
much  in  character,  according  to  their  situation,  that  in  order 
to  interpret  their  clinical  significance  aright  it  is  necessary  to 
bear  in  mind  certain  facts  in  connection  with  the  position  and 
relations  of  the  normal  stomach. 

The  adult  stomach  is  situated  in  the  left  hypochondrium  and 
epigastrium,  with  its  long  axis  directed  downwards  and  to  the 
right.  The  median  line  of  the  body  intersects  the  pyloric  region 
in  such  a  manner  that  nearly  five-sixths  of  the  organ  lie  in  the 
left  half  of  the  abdomen  (Luschka).  The  cardiac  orifice  is 
situated  behind  the  seventh  left  costal  cartilage,  at  its  junction 
with  the  sternum,  and  is  covered  by  the  left  lobe  of  the  liver. 
The  highest  part  of  the  viscus  is  the  upper  margin  of  the 
fundus,  which  reaches  to  the  level  of  the  fifth  rib.  The  lesser 
curvature  descends  perpenclicularl}-  along  the  left  side  of  the 
spinal  column  to  the  first  lumbar  vertebra,  where  it  crosses 
abruptly  to  the  right  to  terminate  at  the  pylorus.     When  the 


PHYSICAL  SIGNS 


165 


stomach  is  empty  the  pylorus  corresponds  to  the  inner  end  of 
the  eighth  right  cartilage  just  outside  the  parasternal  line  ;  but 
when  the  viscus  is  distended  it  may  move  two  or  three  inches 
to  the  right  of  a  line  drawn  from  the  tip  of  the  ensiform 
cartilage  to  the  umbilicus,  while  at  the  same  time  the  great 
curvature  comes  nearer  to  the  abdominal  wall  and  the  anterior 
surface  looks  more  upwards.  The  lower  border  of  the  organ  is 
very  variable  in  its  position,  even  in  p3rsons  who  enjoy  perfect 
health,  but  as  a  rule  it  reaches  as  far  as  a  line  drawn  between 
the  cartilages  of  the  ninth  ribs. 


Fig.  39. — Situation  of  the  normal  stomach.     1,  stomach  ;  2,  liver 
3,  heart ;  4,  lungs  ;  6,  transverse  colon.     (Eichhorst.) 


These  facts  indicate  that  only  the  lower  halves  of  the 
pyloric  and  central  thirds  of  the  stomach  come  into  contact 
with  the  anterior  abdominal  wall,  and  that,  consequently,  only 
those  growths  which  are  situated  in  these  regions  are  invari- 
ably palpable.  On  the  other  hand,  tumours  of  the  cardia,  of 
the  fundus,  or  of  the  posterior  gastric  wall,  are  rarely  felt  until 
they  have  attained  a  considerable  size  or  have  occasioned  dis- 


166  CANCEE  OF  THE   STOMACH 

location  of  the  stomach  ;  while  those  of  the  pylorus,  by  develop- 
ing adhesions  to  the  under  surface  of  the  liver,  are  also  apt  to 
escape  detection. 

General  Characters  of  the  Gastric  Tumour. — (a)  Frequency. 
According  to  the  statistics  of  Brinton  and  Lebert,  nearly  80  per 
cent,  of  all  carcinomata  of  the  stomach  are  accompanied  by  a 
palpable  tumour.  Osier  and  McCrae  detected  a  tumour  in  76 
per  cent,  of  their  clinical  cases,  while  in  our  own  series  a 
definite  tumour  was  discovered  in  69  per  cent,  and  an  '  ill- 
defined  tumour  '  or  a  '  sense  of  resistance  '  was  recorded  in  8  per 
cent.  In  the  remaining  23  per  cent,  no  evidence  of  a  growth 
could  be  found  by  examination  of  the  abdomen  during  life.  It 
must,  therefore,  be  admitted  that  a  palpable  tumour  only  exists 
in  four  out  of  every  five  cases  of  carcinoma  of  the  stomach. 
As  might  have  been  expected  from  the  anatomical  relations  of 
the  stomach,  the  discovery  of  a  tumour  varies  with  the  situa- 
tion of  the  disease.  Thus,  in  our  series  81  per  cent,  of  those 
which  were  situated  in  the  body  of  the  stomach  were  detected 
during  life,  of  the  pyloric  growths  71  per  cent.,  and  of  those 
located  at  the  cardia  or  in  the  fundus  only  55  per  cent.  It  is 
also  interesting  to  notice  the  conditions  which  seem  to  have 
been  chiefly  responsible  for  the  non-detection  of  the  tumour. 
Thus,  among  fifty  cases  in  which  no  tumour  wTas  discovered 
during  life — 

The  abdomen  was  distended  with  fluid  in  nineteen,  or  38  per 

cent. 
The   growth  was  situated  deeply  (cardia,  fundus  or  posterior 

wTall)  in  fifteen,  or  30  per  cent. 
The  tumour  was  very  small  in  ten,  or  20  per  cent. 
Excessive  tenderness  prevented  deep  palpation  in  six,  or  12  per 

cent. 

(6)  Size. — The  tumours  vary  greatly  in  size  in  different  cases. 
The  smallest  are  those  which  occur  in  the  form  of  annular 
growths,  of  localised  indurations  of  the  gastric  wall,  or  of  super- 
ficial ulcerations.  Tumours  of  medium  size  are  met  with  in 
disease  of  the  anterior  wall,  of  the  curvatures  and  of  the  pylorus, 
and  where  there  is  considerable  infiltration  of  the  muscular 
and  serous  coats  of  the  viscus;  while  enormous  masses  are 
often  encountered  when  the  neoplasm  has  extended  into  the 
omentum  or  has  given  rise  to  adhesions  between  the  stomach 


PHYSICAL  SIGNS  167 

and  the  intestines  or  the  liver.  Occasionally  a  large  tumour  is 
formed  by  the  entire  stomach,  the  walls  of  which  have  been 
greatly  thickened  by  diffuse  infiltration. 

(c)  Shape. — This  depends  upon  the  anatomical  characters 
of  the  growth.  Pyloric  tumours  are  oval,  rounded,  or  some- 
what tubular ;  those  which  affect  the  anterior  wall  or  the  great 
curvature  are  often  globular  ;  while  those  which  arise  from 
infiltration  of  the  omentum  are  usually  irregular,  nodular,  or 
elongated.  General  infiltration  of  the  gastric  walls  either  gives 
rise  to  a  mass  which  retains  the  normal  contour  of  the  stomach, 
or  produces  a  smooth,  hard,  elongated  swelling,  the  lower 
margin  of  which  is  more  distinct  than  the  upper. 

(d)  Visibility. — In  addition  to  the  abdominal  swelling  due 
to  a  dilated  and  hypertrophied  stomach,  many  of  the  larger 
growths  give  rise  to  tumours  which  are  visible  to  the  naked 
eye.  This  is  particularly  the  case  when  the  pylorus  is  affected 
and  displaced  downwards,  where  the  peritoneum  is  implicated, 
and  where  the  great  curvature  is  the  seat  of  the  disease. 
Tumours  situated  at  the  upper  or  left  extremity  of  the  stomach 
may  only  be  visible  at  the  end  of  inspiration  or  when  the  viscus 
is  distended  with  food  or  gas.  A  visible  tumour  was  observed 
in  19  per  cent,  of  our  cases. 

(e)  Situation. — This  varies  with  the  location  of  the  growth 
in  the  stomach,  the  position  of  the  viscus,  and  the  presence  of 
adhesions.  In  our  own  cases  the  tumour  occupied  the  um- 
bilical region  in  37  per  cent.,  the  epigastrium  in  28  per  cent., 
the  right  hypochondrium  in  17  per  cent.,  the  left  hypochon- 
drium  in  16  per  cent.,  and  the  hypogastrium  in  2  per  cent. 
The  fact  that  the  majority  are  found  near  the  umbilicus  is  due 
to  the  downward  displacement  of  the  pylorus  which  accom- 
panies gastric  dilatation,  and  to  the  great  tendency  of  all 
growths  in  this  region  to  extend  into  the  walls  of  the  organ. 
The  epigastrium  is  the  usual  site  of  tumours  which  arise  from 
disease  of  the  upper  border  of  the  stomach,  of  those  formed  by 
implication  of  the  omentum,  and  of  growths  which  are  ad- 
herent to  the  liver.  The  right  hypochondrium  is  chiefly 
affected  when  a  pyloric  growth  is  very  large,  or  when  it  has 
involved  the  liver  or  gall-bladder.  A  tumour  formed  by 
disease  of  the  fundus  or  of  the  entire  stomach  is  commonly 
situated  in  the  left  hypochondrium,  while  the  hypogastrium  is 
affected  only  in  those  rare  instances   where  a  pyloric  growth 


168 


CANCEE  OF  THE   STOMACH 


has  been  dragged  downwards  by  the  weight  of  the  enlarged 
stomach. 

(/)  Tenderness. — This  is  almost  invariably  present,  though 
it  varies  in  degree  in  different  cases.  It  is  most  marked  when 
the  tumour  is  ulcerated,  is  of  rapid  growth,  or  has  infected 
the  peritoneum.  As  a  rule,  neoplasms  of  the  central  region 
of  the  stomach  are  accompanied  by  greater  tenderness  than 
those  of  the  pylorus,  annular  strictures  of  the  latter  being 
often  painless. 

(g)  Mobility. — Tumours  of  the  stomach  almost  always 
exhibit  a  certain  degree  of  mobility,  which  varies  according  to 
their  situation  and  external  attachments. 

Movement  with  Respiration. — It  is  usually  taught  that  a 
gastric  tumour  descends  upon  inspiration  only  when  it  is 
attached  to  the  liver,  the  spleen,  or  the  diaphragm.  Such  a 
statement,  however,  is  totally  at  variance  with  fact ;  for  unless 
adhesions  exist  which  bind  the  organ  to  the  abdominal  wall,  the 

pancreas,  or  the  spine,  a  down- 
ward movement  of  the  tumour 
with  each  inspiration  can  invari- 
ably be  detected  by  the  hand,  if 
not  by  the  naked  eye.  As  a  rule, 
the  excursion  is  greatest  in  the 
female,  owing  to  the  displace- 
ment of  the  abdominal  viscera 
which  is  so  often  produced  by 
the  pressure  of  corsets.  It 
is  also  very  marked  in  the 
subjects  of  emphysema.  The 
change  in  the  position  of  the 
tumour  as  the  result  of  an 
inspiratory  effort  not  only  indi- 
cates its  connection  with  one  of 
the  movable  abdominal  viscera, 
but  also  constitutes  a  valuable 
aid  to  its  detection,  since  many  growths  of  the  lesser  curvature 
and  of  the  cardiac  region  of  the  stomach  remain  concealed  by 
the  ribs  unless  pushed  downwards  by  a  forcible  contraction  of 
the  diaphragm.  Moreover,  if  by  pressure  with  the  hand  the 
tumour  can  be  fixed  at  the  lowest  point  in  its  excursion,  so 
that  it  does  not  recede  towards  the  chest  during  expiration,  it 


Fig.  40.  —  Showing  the  downward  move- 
ment of  the  tumour  upon  inspiration. 


PHYSICAL  SIGNS 


169 


is  obvious  that  no  adhesions  exist  between  it  and  the  liver  or 
diaphragm.  On  the  contrary,  if  this  is  impossible,  and  the 
tumour  slips  upwards  despite  every  attempt  to  restrain  it,  the 
growth  will  always  be  found  to  be  attached  to  some  organ 
in  connection  with  the  diaphragm. 

Mechanical  Mobility. — Many  localised  tumours  of  the 
stomach  may  be  displaced  by  pressure  with  the  hand.  The 
most  mobile  are  those  situated  at  the  pylorus,  which  may 
sometimes  be  moved  several  inches  in  every  direction ;  while 
occasionally  growths  of  the  anterior  wall,  or  of  the  entire 
viscus,  are   susceptible    of   displacement    both   vertically   and 


Fig.  41. — Showing    the    mobility    of   a     Fig.  42.— Showing     the    mobility   of   a 
pyloric    tumour   when  free   from  ad-  growth  of   the   anterior    wall   when 

hesions.  free  from  adhesions. 


laterally.  This  form  of  mobility  is  diminished  or  entirely 
prevented  by  adhesion  of  the  growth  to  the  liver,  pancreas,  or 
abdominal  wall,  or  by  its  fixation  in  the  upper  abdomen  by  its 
own  bulk. 

Alterations  in  the  size  of  the  stomach  exercise  a  notable 
influence  upon  the  position  of  the  tumour.  For  this  reason 
it  is  always  advisable  to  record  the  exact  location  and  ap- 
parent size  of  the  growth  upon  the  skin  when  the  viscus  is  empty, 
and  to  repeat  the  process  after  the  stomach  has  been  distended 
with  water  or  gas.  Under  these  conditions  it  may  usually  be 
observed  :  (1)  That  tumours  of  the  upper  margin  which  were 
not  palpable  in  the  first  instance  become  apparent  when  the 


170 


CANCEE  OF  THE   STOMACH 


stomach  is  inflated ;  (2)  that  tumours  of  the  pylorus  descend 
downwards  and  to  the  right,  those  of  the  great  curvature 
downwards,  and  those  of  the  fundus  downwards  and  to  the 
left  ;  (3)  that  growths  of  the  anterior  surface  become  more 
distinct,  and  often  ascend  slightly,  owing  to  the  upward  rotation 
of  the  wall  of  the  organ.  Conversely,  a  patient  who  exhibits 
great  dilatation  of  the  stomach  with  an  ill-defined  tumour  in  the 
right  hypochondrium  when  first  examined,  will  often  present  a 
comparatively  large  tumour  in  the  epigastrium,  or  even  in  the 
left  hypochondrium,  when  the  organ  has  been  emptied  by  a 
tube,    owing   to    the    diminution  in  the  bulk  of  the  stomach 

and  the  consequent  retreat  of 
the  pylorus  towards  the  median 
line. 

The  condition  of  the  trans- 
verse colon  also  produces  a 
notable  effect  upon  the  location 
and  palpability  of  a  gastric 
tumour.  Thus,  many  growths 
appear  to  descend  and  to  be- 
come more  distinct  after  the 
bowels  have  been  evacuated, 
while  distension  of  the  colon 
with  gas  causes  them  to  ascend, 
and  sometimes  to  become  ob- 
scured beneath  the  margin  of 
the  ribs. 

(h)  Pulsation. — In  17  per 
cent,  of  our  cases  the  tumour 
was  stated  to  have  exhibited 
pulsation.  This  phenomenon  was  never  observed  with  growths 
of  the  cardia,  and  was  five  times  as  frequent  in  tumours  of 
the  pylorus  as  in  those  of  the  body  of  the  stomach.  The 
movement  is  invariably  derived  from  the  underlying  aorta,  and 
is  therefore  antero-posterior  in  direction  and  never  eccentric, 
as  in  cases  of  aneurysm.  Occasionally  the  aorta  itself  is 
displaced  to  the  right  by  the  mass,  or  it  is  so  compressed 
that  it  becomes  dilated  above  the  site  of  its  obstruction  (Ott). 
According  to  Gabbi,  compression  of  the  aorta  or  of  the  coeliac 
axis  by  a  diffuse  growth  may  produce  a  thrill  and  a  loud  sys- 
tolic   bruit.     In    one    of   our   cases    an    abdominal    aneurysm 


Fig.  43.—  Showing  the  movement  of  a 
pyloric  tumour  upon  inflation  of  the 
stomach. 


PHYSICAL  SIGNS  171 

coexisted  with  carcinoma  of  the  pylorus,  and  led  to  an  erro- 
neous diagnosis. 

(i)  Percussion. — When  the  tumour  is  situated  immediately 
behind  the  abdominal  wall,  light  percussion  produces  a  dull 
note  and  strong  percussion  a  form  of  tympanitic  dulness.  A 
large  intragastric  growth  attached  to  the  upper  margin  or 
the  posterior  surface  is  usually  comparatively  dull  when  the 
stomach  is  empty,  but  presents  a  tympanitic  note  when  the 
viscus  is  filled  with  gas.  The  percussion-note  over  tumours  of 
the  pylorus  and  of  the  great  curvature  is  often  obscured  by  a 
superimposed  and  adherent  colon. 

(k)  Auscultation. — Gurgling  sounds  may  often  be  detected 
over  the  pylorus  during  the  efforts  of  the  hypertrophied 
stomach  to  force  its  contents  through  the  contracted  orifice, 
and  a  similar  phenomenon  may  sometimes  be  heard  at  the 
centre  of  the  viscus  in  cases  of  hour-glass  stricture.  Stenosis 
of  the  cardia  is  associated  with  retardation  or  entire  suppres- 
sion of  the  deglutition  sounds.  Occasionally  pressure  of  the 
growth  upon  the  aorta  or  cceliac  axis  produces  a  systolic  mur- 
mur, which  is  audible  over  the  epigastrium  and  back. 

(I)  Increase  of  Size. — All  varieties  of  carcinomatous  tumours 
exhibit  an  increase  of  size,  which  is  most  rapid  in  the  softer 
forms  of  growth. 

Changes  of  shape  or  the  development  of  a  nodular  surface 
usually  indicate  an  extension  of  the  disease  to  the  peritoneum 
or  other  neighbouring  structures. 

Diminution  or  disappearance  of  the  tumour  is  occasionally 
observed  when  the  major  portion  of  the  growth  has  been 
destroyed  by  sloughing,  or  after  the  establishment  of  an 
internal  fistula. 

Special  Features. — (1)  Tumours  of  the  Pylorus. — These 
constitute  about  60  per  cent,  of  all  gastric  tumours,  and  three 
out  of  every  four  (75  per  cent.)  may  be  recognised  by  palpa- 
tion at  one  period  or  other  of  the  disease.  Three  conditions 
militate  against  their  detection,  viz.  localisation  of  the  growth 
at  the  orifice,  adhesion  to  the  under  surface  of  the  liver,  and 
distension  of  the  abdomen  by  fluid  or  gas. 

In  itself  a  pyloric  tumour  is  seldom  of  great  size,  a  large 
nodular  mass  being  usually  due  to  extensive  thickening  of  the 
omentum,  adhesion  of  the  pylorus  to  the  colon,  duodenum,  or 
the  gall-bladder,  or  to  enlargement  of  the  perigastric  glands. 


172 


CANCER  OF  THE   STOMACH 


That  form  of  carcinoma  which  produces  the  greatest  dilata- 
tion of  the  stomach  is  a  contracting  scirrhus,  and  consequently 
the  size  of  a  pyloric  tumour  is  usually  inversely  proportionate 
to  that  of  the  stomach.  On  the  other  hand,  a  considerable 
degree  of  gastrectasis  may  ensue  from  an  infiltration  of  the 
pyloric  half  of  the  organ,  only  a  portion  of  which  produces  a 
palpable  tumour.  These  considerations  tend  to  establish  three 
facts :  (1)  That  palpation  affords  no  clue  to  the  real  size  or 
extent  of  the  growth,  which  a  necropsy  usually  proves  to  be  at 
least  twice  as  large  as  its  physical  signs  seemed  to  indicate 
during   life.     (2)   That  extreme    dilatation  of  the  stomach  is 

seldom  associated  with  a  large 
tumour,  and  very  often  with 
none  at  all.  (3)  That  the  great 
bulk  of  a  large  tumour  is  due 
to  implication  of  the  omentum 
and  other  viscera  in  the 
vicinity  of  the  pylorus. 

The  shape  of  a  pyloric 
tumour  varies  considerably, 
being  round,  oval,  irregular, 
or  elongated,  according  as  the 
viscus  itself  or  the  surrounding- 
structures  constitute  the  bulk 
of  the  mass.  In  most  in- 
stances it  is  situated  slightly 
above  and  to  the  right  of  the 


Fig.  44. — Showing  the  downward  dis- 
placement of  a  pyloric  tumour  free 
from  adhesions  by  the  traction  of  a 
dilated  stomach. 


umbilicus,  and  close  to  the 
median  line  of  the  abdomen ; 
but  when  the  stomach  is  dilated 
it  is  often  felt  outside  the  right  parasternal  line,  while  if  the 
organ  is  empty  it  may  be  located  in  the  epigastrium  or  left 
hypochondrium.  In  the  absence  of  adhesions  the  weight  of 
the  enlarged  stomach  gradually  displaces  the  pylorus  down- 
wards, so  that  the  tumour  may  eventually  present  itself  in  the 
hypogastrium,  or  even  in  the  pelvis. 

Mobility  is  usually  a  marked  feature  ;  the  descent  upon 
inspiration  being  greatest  when  the  growth  is  adherent  to  the 
liver,  while  if  the  tumour  is  not  attached  to  the  surrounding 
viscera  it  can  be  moved  in  various  directions  by  the  application 
of   pressure.     Tenderness    may  or   may    not    exist,  and  when 


PHYSICAL  SIGNS 


173 


grasped  by  the  hand  the  left  extremity  of  the  mass  may 
sometimes  be  felt  to  alternately  harden  and  relax  with  each 
peristaltic  movement  of  the  hypertrophied  stomach.  At  such 
times  gurgling  may  be  both  heard  and  felt  in  the  neighbour- 
hood of  the  tumour,  and  the  mass  may  pulsate  owing  to  its 
proximity  to  the  aorta. 

(2)  Tumours  of  the  Body  of  the  Stomach  (Walls  and 
Curvatures). — These  are  usually  situated  in  the  epigastric  or 
umbilical  region,  and  are  often  of  considerable  size.  In  shape 
they  are  globular,  elongated,  or  irregular,  and  the  surface  is 
frequently  nodular  from  implication  of  the  omentum.  In  most 
cases  they  descend  upon  inspiration  ;  but  lateral  mobility  seldom 
exists  to  any  great  extent,  since  it  is  usually  abolished  at  an 
early  period  by  the  formation  of  adhesions.  Growths  of  the 
anterior  surface  and  of  the  greater  curvature  are  always  distinct, 
and  often  exhibit  a  rapid  increase  of  size,  while  those  of  the 
lesser  curvature  may  be  detected  only  on  deep  inspiration.  All 
varieties  afford  a  dull  note  on  light  percussion  and  a  tympanitic 
sound  with  a  forcible  stroke  of  the  finger.  Inflation  of  the 
stomach  obscures  a  tumour  of  the  upper  margin,  but  renders 
those  of  the  great  curvature  more  distinct.  Distension  of  the 
colon  displaces  them  all  up- 
wards. A  growth  of  the  pos- 
terior wall  of  the  stomach 
seldom  forms  a  palpable  tumour. 

(3)  Tumours  of  the  Cardia. 
Small  growths  in  the  immediate 
vicinity  of  the  cardiac  orifice 
can  never  be  detected  by  pal- 
pation, but  should  they  extend 
to  the  lesser  curvature  or  to  the 
fundus  of  the  stomach  they 
may  give  rise  to  definite 
tumours.  Carcinoma  of  the 
fundus  usually  produces  a 
mass  which  is  located  in  the 
left  hypochondnum,  and  which 
at  first  can  be  felt  only  on  deep 
inspiration  or  after  inflation  of 

the  stomach.  At  a  later  period  it  often  projects  below  the 
costal  margin  and  extends  towards  the  umbilicus.     In  most 


Fig.  45.—  Showing  the  forms  of  tumour 
which  may  be  met  with  in  disease  of 
the  cardia  and  fundus. 


174 


CANCEE  OF  THE   STOMACH 


instances  the  growth  is  particularly  rapid,  great  tenderness  is 
present,  and  the  surface  of  the  tumour  is  nodular,  owing  to  an 
implication  of  the  omentum.  General  cancerous  peritonitis 
is  apt  to  follow  disease  of  this  region  of  the  organ  and  to 
obscure  the  original  growth ;  while  not  infrequently  the  mass 
becomes  fixed  to  the  abdominal  wall  or  to  the  costal  cartilages. 
(4)  Tumours  composed  of  the  Entire  Stomach. — A  palpable 
tumour  may  be  formed  by  the  entire  stomach  under  two  con- 
ditions :  (a)  Obstruction  of  the  cardiac  orifice  with  contraction 
of  the  empty  viscus ;  (5)  general  infiltration  of  the  gastric  walls 
by  the  malignant  growth. 


Figs.    46,  47. — Showing    the  fornis  of  tumour  sometimes  met  with  in  cases  of 
total  infiltration  of  the  stomach. 


(a)  It  is  only  in  rare  cases  that  obstruction  to  the  entry  of 
food  is  followed  by  shrinkage  of  the  stomach  to  such  a  degree 
that  it  can  be  felt  as  a  round  or  somewhat  elongated  tumour  in 
the  left  hypochondrium  or  contiguous  portion  of  the  epigastrium. 
In  such  cases  the  mass  when  grasped  by  the  hand  may  some- 
times be  felt  to  harden  and  relax  alternately.  The  normal 
outlines  of  the  stomach  cannot  be  defined,  and  the  region  usually 
occupied  by  the  viscus  is  filled  by  the  colon. 

(b)  General  infiltration  of  the  gastric  walls  may  be  accom- 
panied by  an  oval  or  elongated  tumour  which  projects  from 
below  the  left  costal  margin  into  the  epigastrium,  and  can  often 
be  grasped  between  the  hands.     The  lower  margin  is  usually 


PHYSICAL  SIGNS  175 

hard  and  well  defined,  but  the  upper  is  indistinct,  especially 
towards  its  left  extremity.  The  surface  is  smooth  or  some- 
what nodular,  tender  upon  pressure,  and  comparatively  dull  on 
percussion.  At  first  the  whole  mass  moves  with  respiration, 
and  can  be  displaced  from  side  to  side  to  the  extent  of  an  inch 
or  more  ;  but  with  the  progress  of  the  complaint  it  often 
becomes  fixed  by  peritoneal  adhesions.  Unlike  other  gastric 
tumours,  it  does  not  increase  in  size  unless  the  omentum  be- 
comes infected,  but,  on  the  contrary,  gradually  grows  smaller, 
harder,  and  more  distinct.  During  the  later  stages  of  the  com- 
plaint it  is  often  obscured  by  ascites. 

Enlargement  of  Lymphatic  Glands.— The  fact  that  glandu- 
lar tumours  occasionally  develop  above  the  left  clavicle  has  long 
been  known,  but  the  frequency  of  their  occurrence  and  their 
clinical  significance  have  been  much  exaggerated.  Thus,  while 
some  writers  refer  to  the  presence  of  palpable  glands  in  that 
position  as  pathognomonic  of  gastric  cancer  (Friedreich,  Henoch) , 
others  state  that  they  may  be  detected  in  the  majority  of  the 
cases.  To  both  these  statements  we  are  obliged  to  take 
exception.  In  the  first  place,  in  most  diseases  that  are  accom- 
panied by  great  emaciation  one  or  more  glands  may  be  felt  in 
the  left  supraclavicular  fossa,  while  not  a  few  examples  of 
malignant  disease  of  the  stomach  present  old  tubercular  lesions 
in  that  position.  Again,  among  a  series  of  cases  of  gastric 
cancer  which  we  examined  with  special  reference  to  this 
point,  nearly  11  per  cent,  exhibited  supraclavicular  glands 
which  could  be  easily  felt,  but  in  no  instance  did  microscopic 
examination  after  death  indicate  any  malignant  infection  of  the 
cervical  lymphatics.  On  the  other  hand,  the  gradual  develop- 
ment of  a  glandular  tumour  in  the  neck,  axilla,  or  groin,  which 
tends  to  become  adherent  to  the  skin  and  subjacent  structures, 
must  always  be  regarded  as  an  indication  of  considerable 
importance.  In  our  hospital  series  tumours  of  this  character 
were  observed  above  the  left  clavicle  in  3  per  cent.,  above  the 
right  clavicle  in  0-5  per  cent.,  in  the  left  axilla  in  1  per  cent., 
and  in  the  inguinal  region  in  2  per  cent. 

As  a  rule  the  glandular  enlargement  does  not  appear  until  a 
late  stage  of  the  disease,  and  almost  invariably  indicates  exten- 
sive infection  of  the  mediastinal  or  mesenteric  lymphatics, 
but  when  the  gastric  symptoms  are  latent  the  glandular  tumour 
is    occasionally   the    first    sign  to    attract    attention    (Lepine). 


176  CANCEE  OE  THE   STOMACH 

Enlargement  of  the  glands  in  the  left  axilla  is  usually  secondary 
to  involvement  of  those  above  the  clavicle,  while  a  growth  in 
the  right  supraclavicular  space  indicates  the  existence  of  meta- 
stases in  the  right  pleura  or  lung.  An  affection  of  the  inguinal 
glands  is  most  common  on  the  right  side,  and  often  accompanies 
a  diffuse  infection  of  the  mesenteric,  lumbar,  and  sacral  glands, 
but  it  is  occasionally  associated  with  metastases  in  the  ovary  or 
other  pelvic  viscera.  In  cases  of  general  carcinosis  all  the 
superficial  glands  are  apt  to  become  enlarged. 


177 


CHAPTEE   VI 

COMPLICATIONS 

Perforation  of  the  Stomach 

Pbeforation  of  the  stomach  occurs  in  at  least  8  per  cent,  of 
all  cases,  but  its  effects  vary  under  different  conditions.  If  no 
adhesions  exist  around  the  base  of  the  disease,  the  gastric  con- 
tents become  diffused  throughout  the  abdominal  cavity  and 
excite  acute  general  peritonitis ;  but  if  the  leakage  is  only 
slight,  or  is  strictly  limited  by  pre-existing  adhesions,  the 
chief  result  of  the  accident  is  the  formation  of  a  localised  intra- 
peritoneal abscess. 

(1)  General  Peritonitis.— This  constitutes  the  immediate 
cause  of  death  in  about  3  per  cent,  of  all  cases  of  gastric  carcinoma, 
and  is  most  common  when  perforation  occurs  on  the  anterior 
surface  of  the  organ,  near  the  pylorus.  The  fact  that  the  accident 
does  not  usually  ensue  until  a  late  period  of  the  disease,  when 
the  patient  is  suffering  from  profound  exhaustion,  renders  its 
attendant  symptoms  less  conspicuous  than  those  which  usually 
accompany  perforation  of  the  stomach.  In  those  rare  instances, 
however,  where  an  attack  of  acute  general  peritonitis  is  the 
first  indication  of  the  disease,  its  onset  is  equally  abrupt  and  its 
symptoms  quite  as  characteristic  as  in  cases  of  simple  ulcer 
(Watson,  Ellis). 

Perforation  may  occur  suddenly  and  without  warning,  or  it 
maybe  preceded  for  some  days  by  an  increase  of  pain,  excessive 
vomiting,  or  by  profuse  haeinatemesis,  the  two  latter  symptoms 
being  particularly  frequent  when  the  morbid  growth  has  been 
destroyed  by  sloughing.  In  other  cases  excessive  distension  of 
the  stomach,  violent  vomiting,  or  straining  at  stool  appears  to  be 
the  immediate  cause  of  the  rupture.  As  a  rule,  pain  in  the  abdo- 
men is  the  most  conspicuous  of  the  early  symptoms  ;  but  if  great 
debility  exists,  or  the  gastric  complaint  has  been  accompanied 

N 


178  CANCEE  OF  THE   STOMACH 

throughout  by  considerable  suffering,  its  significance  is  liable 
to  escape  attention  (Given).     In  debilitated  or  insane  subjects, 
and  also  in  those  where  the  peritoneum  has  been  implicated  by 
the  malignant  disease,  the  abdominal  pain  is  often  slight,  or  even 
entirely  absent.     Vomiting  is  also  an  inconstant  symptom,  and 
when  it  exists  does  not  materially  differ  from  that  which  was 
previously  present.     The   most  important  indication   of   per- 
foration is  the  general  appearance  of  the  patient.      In  every 
instance,  whether  pain  and  vomiting  exist  or  not,  a  rapid  access 
of  weakness  may  be  observed,  and  within  a  few  hours  the  face 
assumes    an    expression   that   is   highly   suggestive   of    acute 
peritonitis.     The  cheeks  seem  to  shrink,  the  eyes  recede  into 
their  sockets,  the  nose  becomes  pinched,  and  the  skin  exhibits 
a  bluish  or  dusky  hue.     At  the  same  time  the  temperature  of 
the  body  is  markedly  depressed,  the  extremities  become  cold, 
the  pulse  is   small,  quick,  and  feeble,   and  the  surface  of  the 
body   is    often  bedewed  with  a  cold  sweat.     Examination  of 
the  abdomen  usually  reveals  a  moderate  degree  of  distension, 
with  some  rigidity  of  the  walls   and  general  tenderness ;  but 
complete   flaccidity    of  the  tissues    and  an    entire  absence  of 
pain  are  quite  compatible  with  suppurative  peritonitis.     Ob- 
scuration of  the  hepatic    dulness  from   the    presence  of  free 
gas  in  the  abdominal  cavity  is  rarely  to  be  observed,  owing 
to  the  frequent  existence  of  adhesions  or  ascites.     Eetention 
of  urine  is  sometimes  an  important  sign,  and  should  diarrhoea 
have   previously   existed   the    sudden    onset    of    constipation 
seldom  fails  to  attract  attention.      Life  is  rarely  prolonged  for 
more  than  forty-eight  hours. 

(2)  Perigastric  Abscess. — A  localised  collection  of  pus  as 
the  result  of  perforation  occurs  in  3  to  5  per  cent,  of  all  cases 
of  carcinoma  of  the  stomach,  and  is  rather  more  frequent  in 
disease  of  the  cardia  than  of  the  pyloric  end  of  the  organ. 

When  the  abscess  is  small  in  size  and  deeply  situated,  it  is 
seldom  accompanied  by  any  special  symptoms.  As  a  rule, 
there  is  some  increase  of  the  abdominal  pain,  which,  if  pre- 
viously intermittent,  becomes  constant  and  may  be  associated 
with  frequent  retching.  The  temperature  is  somewhat  ele- 
vated, and  chills,  or  even  rigors,  may  occur,  while  increasing 
debility  and  anaemia  are  invariably  present.  The  physi- 
cal signs  chiefly  consist  of  fulness  and  tenderness  of  the 
epigastrium.     Death  usually  occurs  from  exhaustion,  and  the 


COMPLICATIONS  179 

discovery  of  an  abscess  at  the  necropsy  is  often  quite  unex- 
pected. 

The  larger  collections  of  pus  generally  form  beneath  the  left 
wing  of  the  diaphragm,  or  between  the  stomach  and  the 
abdominal  wall.  In  the  former  case  pain  and  dyspnoea  are 
prominent  symptoms,  rigors  are  not  infrequent,  and  the 
temperature  may  be  elevated  several  degrees.  The  epigastrium 
and  left  hypochondrium  are  distended  and  tender  on  palpation ; 
the  abdominal  walls  are  rigidly  contracted,  and  no  movement  of 
the  diaphragm  can  be  detected  on  deep  inspiration.  "Within  a 
short  time  the  affected  side  of  the  chest  becomes  enlarged,  and 
its  lower  ribs  are  thrown  outwards,  so  that  the  costal  angle  is 
increased.  The  intercostal  spaces  are  also  widened,  and  may 
bulge  to  some  extent.  The  displacement  of  the  liver  and 
spleen  is  often  obscured  by  the  tenderness  and  rigidity  of  the 
abdominal  wall,  but  careful  percussion  will  usually  show  that  the 
left  hepatic  lobe  projects  into  the  epigastrium.  In  almost  every 
instance  the  heart  is  tilted  upwards,  and  its  apex  may  be  felt  in 
the  fourth  intercostal  space,  rather  to  the  left  of  its  normal  posi- 
tion. The  base  of  the  left  lung  is  compressed  and  partially 
deprived  of  air,  so  that  the  percussion-note  over  the  left  pos- 
terior base  is  comparatively  dull  and  the  respiratory  murmur 
diminished.  This  condition  is  distinguished  from  pleuritic 
effusion  by  an  increase  of  tactile  fremitus  and  vocal  resonance 
over  the  affected  area,  and  by  the  occasional  existence  of  moist 
crepitations.  The  presence  of  gas  in  the  abscess-sac  beneath  the 
diaphragm  gives  rise  to  a  tympanitic  note  over  the  front  of  the 
left  chest  as  far  upwards  as  the  fourth  rib,  which  may  extend 
across  the  sternum  to  the  right  nipple-line  and  downwards  to 
the  right  costal  margin,  where  it  merges  with  the  hyper- 
resonance  of  the  epigastrium.  On  auscultation  over  the  front 
and  lateral  aspects  of  the  left  chest  the  vesicular  murmur  is 
found  to  be  either  absent  or  replaced  by  loud  amphoric  breath- 
ing. The  latter  phenomenon  is  usually  due  to  an  alteration  in 
the  breath-sounds  produced  by  their  transmission  through  the 
gas-containing  cavity ;  but  it  is  also  possible  that  in  some  cases 
a  communication  between  the  stomach  and  the  abscess  may 
permit  an  interchange  of  gas  with  each  movement  of  the  dia- 
phragm. When  the  subphrenic  abscess  contains  a  large  quan- 
tity of  both  pus  and  gas,  metallic  tinkling  is  often  audible  after 
coughing,  or  a  loud  succussion  sound  may  be  produced  by  move- 

N    2 


180  CANCEE   OP  THE    STOMACH 

ment  of  the  body.  Finally,  it  may  be  noticed  that  when  two 
coins  are  clinked  together  over  the  abscess  a  bruit  d'airain 
may  be  heard  over  the  affected  area. 

A  circumscribed  abscess  due  to  perforation  of  the  anterior 
wall  of  the  stomach  is  usually  situated  in  the  epigastric,  left 
hypochondriac,  or  umbilical  region,  where  it  produces  a  rounded 
and  tender  swelling.  Owing  to  the  existence  of  adhesions  the 
tumour  does  not  move  with  respiration,  nor  can  it  be  displaced 
by  manipulation.  The  percussion-note  over  it  varies  accord- 
ing to  its  contents,  being  dull  when  they  consist  of  fluid,  but 
resonant  when  a  large  amount  of  gas  is  present. 

An  abscess  situated  behind  the  stomach  in  the  lesser  cavity 
of  the  peritoneum  is  rarely  accompanied  by  any  signs  of 
importance,  and  in  most  cases  moderate  fever  of  a  hectic  type, 
and  increasing  debility  and  anaemia,  are  the  only  symptoms 
which  indicate  the  existence  of  suppuration.  If  the  pus  bursts 
into  the  stomach,  it  may  appear  in  the  vomit. 

The  duration  of  life  in  cases  of  perigastric  abscess  varies 
according  to  the  stage  of  the  gastric  complaint  at  which  it 
ensues  and  the  intensity  of  the  local  inflammation.  If  the  sac 
is  small  in  size,  the  fatal  event  may  be  postponed  for  several 
weeks ;  but  when  a  large  quantity  of  pus  accumulates  in  the 
immediate  vicinity  of  the  diaphragm,  death  usually  takes  place 
within  a  week  or  ten  days. 

Fistulse 

(1)  Gastro-colic  Fistula. — A  fistulous  communication  be- 
tween the  stomach  and  the  transverse  colon  occurs  in  about 
25  per  cent,  of  all  cases  of  gastric  carcinoma,  and  is 
most  frequent  when  the  primary  growth  involves  the  great 
curvature  (vide  p.  49).  This  complication  only  ensues  at  an 
advanced  stage  of  the  complaint,  and  its  symptoms  vary 
according  to  the  size  of  the  aperture  between  the  two  viscera. 
As  a  rule,  the  rupture  of  the  intestinal  wall  is  not  accom- 
panied by  any  noticeable  symptoms,  but  occasionally  the 
patient  experiences  a  sudden  and  severe  pain  in  the  abdomen, 
which  may  be  accompanied  by  retching,  shivering,  or  diarrhoea. 

FcBcal  vomiting  is  chiefly  observed  when  the  fistula  is  of 
large  size  and  the  pylorus  is  free  from  disease,  since  the  esta- 
blishment of  a  secondary  opening  in  a  stomach  which  is  greatly 
dilated  from  pyloric  stenosis  usually  relieves  the  previous  vomit- 


COMPLICATIONS  181 

ing,  by  permitting  the  contents  of  the  viscus  to  escape  into  the 
bowel.  On  the  other  hand,  a  small  or  valvular  opening  in  the 
colon  may  only  be  accompanied  by  a  fsecal  odour  in  the  ejecta 
or  an  intensely  foul  taste  in  the  mouth.  The  passage  of 
undigested  food  immediately  after  it  has  been  swallowed 
(lienteric  diarrhoea)  is  another  important  indication  of  a  gastro- 
colic fistula,  and  usually  replaces  the  periodic  vomiting  from 
which  the  patient  previously  suffered.  In  every  case  the 
intestinal  complication  is  accompanied  by  a  rapid  increase  of 
the  debility  and  cachexia,  and  death  usually  ensues  within  a 
fortnight  of  its  development. 

Diagnosis. — A  gastro-colic  fistula  is  seldom  difficult  to 
recognise  when  accompanied  by  fsecal  vomiting  or  lienteric 
diarrhoea,  but  when  it  merely  produces  an  unpleasant  odour  in 
the  breath  or  the  vomit  it  is  liable  to  be  overlooked.  Eeeves 
was  the  first  to  notice  that  enemata  are  often  vomited  if  much 
force  has  been  employed  in  their  administration  ;  and  this  fact 
is  of  considerable  value  in  diagnosis,  since  the  rejection  of  a 
coloured  fluid  soon  after  it  has  been  injected  into  the  bowel 
necessarily  indicates  the  existence  of  an  abnormal  communica- 
tion between  the  colon  and  the  stomach.  In  one  case  v. 
Ziemssen  was  able  to  detect  the  fistula  by  observing  that  when 
gas  was  introduced  into  the  rectum  it  escaped  into  the 
stomach  without  distending  the  colon.  According  to  Levin- 
stein, loud  gurgling  sounds  may  be  heard  over  the  site  of  the 
fistula  upon  auscultation  of  the  abdomen.  The  formation  of 
a  fistula  between  the  stomach  and  the  small  intestine  can  only 
be  surmised  by  the  sudden  subsidence  of  vomiting  and  other 
symptoms  of  dilatation  of  the  stomach,  and  their  replacement 
by  diarrhoea. 

(2)  Gastro-cutaneous  Fistula. — This  condition  is  much 
less  frequent  as  the  result  of  cancer  than  of  simple  ulcer  of  the 
stomach,  and  occurs  in  only  026  per  cent,  of  the  cases  of  the 
former  disease  (vide  p.  51).  It  is  interesting  to  observe  that 
out  of  the  nineteen  cases  which  have  been  recorded,  fourteen 
occurred  in  women  and  only  five  in  men,  the  average  age  in 
the  former  sex  being  forty-two  and  in  the  latter  fifty-six  years. 
In  every  instance  the  formation  of  the  fistula  was  preceded  for 
some  time  by  a  palpable  tumour,  which  usually  occupied  the 
umbilical  region,  but  occasionally  presented  itself  in  the  left  or 
even  in  the  right  hypochondrium.     Pain  was  invariably  present, 


182  CANCER   OF  THE   STOMACH 

and  the  temperature  of  the  body  was  often  elevated.  In  those 
cases  which  were  not  subjected  to  surgical  treatment  adhesion 
of  the  growth  to  the  abdominal  wall  was  followed  by  redness 
and  oedema  of  the  skin,  subcutaneous  emphysema,  and  finally 
by  the  discharge  of  a  small  quantity  of  turbid  fluid  through 
one  or  more  openings  at  the  summit  of  the  tumour.  The 
discharge  consisted  of  pus,  serum,  or  of  a  greyish  fetid  material, 
which,  after  an  interval  that  varied  from  eleven  days  (Petit)  to 
a  month  (Auger),  became  mixed  with  particles  of  food.  The 
introduction  of  a  probe  revealed  a  cavity  of  some  size  behind 
the  abdominal  wall,  but  no  direct  communication  with  the 
stomach  could  be  discovered.  Death  ensued  from  debility, 
aggravated  by  the  discharge,  and  occurred  at  varying  intervals 
after  the  formation  of  the  fistula,  viz.  three  days  (Fereol),  twenty- 
one  days  (Wencker,  Stokes),  twenty-three  days  (Leflaive),  one 
month  (Cameron,  Ballufi',  Murchison,  Monod),  six  weeks 
(Coote),  seven  weeks  (Feulard),  and  three  months  (Petit,  Auger.) 
As  a  rule  the  intra-peritoneal  abscess  which  preceded  the 
formation  of  the  fistula  was  easily  recognised,  but  in  four 
instances  where  the  patient  was  less  than  thirty-five  years  of 
age  it  was  mistaken  for  tubercular  peritonitis.  In  several  cases 
also  the  connection  of  the  abscess  with  the  stomach  was  not 
surmised  until  after  the  discovery  of  particles  of  food  in  the 
discharge. 

Metastases 

Secondary  growths  occur  so  frequently,  and  exert  such  an 
important  influence  upon  the  symptoms  and  signs  of  the 
gastric  complaint,  that  it  is  necessary  briefly  to  consider  the 
clinical  phenomena  that  attend  their  development  in  the  prin- 
cipal organs  of  the  body. 

(1)  Metastases  in  the  Liver. — Secondary  deposits  are  met 
with  in  the  liver  in  at  least  35  per  cent,  of  all  cases.  In  some 
instances  only  one  or  two  nodules  are  discovered  after  death, 
while  in  others  the  entire  organ  appears  to  be  replaced  by 
aggregated  masses  of  carcinoma.  As  a  rule  the  size  of  the 
individual  metastases  is  inversely  proportionate  to  their  number, 
and  it  is  often  observed  that  the  hepatic  affection  is  most  marked 
when  the  primary  growth  in  the  stomach  is  comparatively 
insignificant.  This  latter  fact  helps  to  explain  the  infrequency 
of    gastric    symptoms  in   cases  where  the  liver   is  extensively 


COMPLICATIONS  183 

involved  at  an  early  period.  The  situation  of  the  growths 
varies  according  to  their  mode  of  formation,  those  produced 
by  infection  of  the  portal  system  usually  developing  in  the 
substance  of  the  organ,  while  those  that  arise  from  infection 
of  the  lymphatics  are  often  situated  beneath  the  capsule. 
The  right  lobe  of  the  liver  is  principally  affected  when  the 
pyloric  and  central  regions  of  the  stomach  are  the  seat  of 
disease,  and  the  left  lobe  in  cases  of  primary  carcinoma  of 
the  cardia.  The  most  rapid  and  extensive  destruction  of  the 
hepatic  tissue  is  associated  with  soft  ulcerated  growths  of  the 
upper  margin  of  the  stomach,  while  a  localised  scirrhus  of 
the  pylorus  which  produces  great  dilatation  of  the  stomach 
is  the  least  malignant  in  this  respect.  The  period  at  which 
the  liver  becomes  affected  varies  greatly  in  different  cases  ;  in 
some  instances  large  tumours  appear  within  three  months  of 
the  onset  of  the  gastric  symptoms,  while  in  others  enlargement 
of  the  organ  is  detected  only  during  the  last  few  weeks  of  life. 
The  rapid  infection  of  the  liver  which  so  often  occurs  during 
the  warm  months  of  the  year  may  be  partly  responsible  for  the 
higher  death-rate  from  carcinoma  of  the  stomach  that  obtains 
between  May  and  September. 

It  is  always  difficult  to  differentiate  between  the  symptoms 
which  arise  from  secondary  disease  of  the  liver  and  those  that 
attend  the  primary  complaint  and  coexisting  metastases  in  other 
organs.  As  a  rule,  however,  secondary  growths  of  the  liver 
are  accompanied  by  severe  and  constant  pain  in  the  right 
hypochondrium  and  back,  which  is  increased  by  exertion  and 
is  often  worse  at  night.  In  every  case,  also,  the  emaciation, 
cachexia,  and  anorexia  become  greatly  increased  when  the  liver 
is  infected,  while  in  many  instances  the  pain  after  food  and 
vomiting  which  previously  existed  tend  to  diminish.  Contrary 
to  the  usual  statements  on  the  subject,  jaundice  is  a  compara- 
tively rare  result  of  the  hepatic  affection,  only  about  one-fifth 
of  the  cases  of  icterus  being  directly  referable  to  it.  Ascites 
occurs  in  about  21  per  cent,  of  the  cases  where  the  liver  is 
affected,  and  in  about  50  per  cent,  of  those  where  there  is  co- 
existing disease  of  the  peritoneum.  In  most  instances  it  is 
only  moderate  in  amount,  and  does  not  appear  until  the  liver  is 
already  much  enlarged.  An  excess  of  urobilin  in  the  urine  is 
supposed  to  accompany  the  destruction  of  the  liver  substance 
by  the  new  growth  (Tissier) . 


184  CANCEE  OF  THE   STOMACH 

The  physical  signs  vary  according  to  the  number  and 
position  of  the  secondary  growths.  When  these  are  few,  and 
situated  deeply  in  the  substance  of  the  right  lobe,  the  liver 
appears  to  be  enlarged  and  presents  a  smooth  surface  and  a 
well-defined  edge,  while  posteriorly  the  area  of  hepatic  dulness 
is  found  to  be  much  increased.  If,  on  the  other  hand,  the 
metastases  project  upon  the  surface,  they  may  usually  be  felt 
in  the  form  of  rounded  tumours,  which  increase  in  size  and  are 
often  very  tender  upon  pressure.  Scirrhous  deposits  are  some- 
times distinctly  concave  or  '  cupped,'  owing  to  the  contrac- 
tion of  their  fibrous  substance.  Carcinoma  of  the  cardia  is 
often  associated  with  enlargement  of  the  left  lobe  of  the  liver,  or 
with  a  nodular  growth  in  that  portion  of  the  organ  situated  in 
the  epigastrium.  A  solitary  tumour  in  the  region  of  the  gall- 
bladder usually  indicates  a  direct  extension  of  carcinoma  into  the 
liver  from  an  adherent  pylorus.  Among  the  minor  indications 
of  the  disease  are  oedema  of  the  legs,  enlargement  of  the  super- 
ficial veins  of  the  abdomen,  and  slight  albuminuria. 

(2)  Metastases  in  the  Peritoneum. — These  exist  in  about 
35  per  cent,  of  all  cases  of  carcinoma  of  the  stomach,  and  occur 
most  frequently  when  the  greater  part  of  the  organ  or  its  upper 
margin  is  affected  by  the  disease.  Secondary  growths  are 
chiefly  met  with  in  the  great  omentum,  which  becomes  con- 
verted into  a  hard,  nodular,  sausage-shaped  mass  adherent  to 
the  anterior  aspect  of  the  stomach  or  colon.  Less  frequently 
the  general  surface  of  the  peritoneum  presents  numerous  dis- 
crete tumours,  which  vary  in  size  from  a  pea  to  a  Tangerine 
orange,  and  are  especially  abundant  in  the  pelvis  and  in  the 
mesentery.  Finally,  in  rare  cases  the  serous  membrane 
exhibits  a  diffuse  miliary  carcinosis,  which  closely  resembles 
tubercle  in  appearance  and  frequently  extends  through  the 
lymphatics  of  the  diaphragm  to  the  pleurae  or  the  pericardium. 
It  is  therefore  obvious  that,  while  secondary  carcinoma  of  the 
peritoneum  may  present  certain  features  which  are  common  to 
each  variety,  the  physical  signs  of  the  disease  vary  according 
to  the  size,  situation,  and  number  of  the  metastases. 

Pain  is  an  inconstant  feature  of  the  complaint,  and  when  pre- 
sent it  is  distinguished  with  difficulty  from  that  which  accom- 
panies the  primary  growth.  It  is  usually  most  conspicuous 
before  the  development  of  ascites,  and  is  especially  severe  in 
cases  of  miliary  carcinosis,  where  its  onset  may  be  so  sudden  as 


COMPLICATIONS  185 

to  simulate  acute  general  peritonitis.  Flatulence  and  constipa- 
tion are  always  marked  symptoms,  and  the  distension  that 
ensues  after  meals  is  a  constant  source  of  complaint.  An 
invasion  of  the  general  peritoneum  is  always  accompanied  by  a 
rapid  failure  of  strength,  and  life  is  seldom  prolonged  for  more 
than  three  months.  The  chief  signs  of  the  disease  consist  of 
ascites  and  the  presence  of  one  or  more  palpable  tumours  in 
the  abdomen. 

Ascites  often  develops  quite  suddenly,  but  it  is  rarely 
excessive,  and  is  apt  to  vary  in  amount  from  time  to  time. 
A  sudden  increase  of  weight  which  is  sometimes  observed 
during  the  course  of  the  gastric  complaint  is  usually  due  to 
peritoneal  effusion.  As  a  rule  the  fluid  is  easily  detected  by 
palpation  and  percussion,  but  when  extensive  adhesions  exist 
between  the  intestines  and  the  abdominal  parietes  it  is  apt  to 
become  encysted,  and  may  then  be  mistaken  for  a  tumour.  In 
cases  of  miliary  carcinoma  the  mesentery  becomes  gradually 
contracted,  with  the  result  that  the  intestines  are  drawn  back- 
wards to  the  spine  and  are  completely  concealed  by  the  serous 
exudation.  Under  these  circumstances  the  anterior  aspect 
of  the  abdomen  is  dull  on  percussion,  while  a  large  tym- 
panitic area  exists  posteriorly  over  the  back  and  loins. 

The  fluid  removed  by  tapping  is  usually  of  a  clear  amber 
colour,  and  according  to  Euneberg  contains  a  much  larger  percen- 
tage of  albumin  (4-6  per  cent.)  than  that  of  dropsical  effusions 
(1^-2^  per  cent.).  Microscopic  examination  of  the  sediment 
sometimes  reveals  clumps  of  cancer  cells,  or  isolated  cells  which 
show  atypical  mitoses.  Colloid  changes  in  the  cells  may  be  de- 
tected. AVhen  the  peritoneal  growths  are  numerous  and  very  soft 
the  fluid  is  often  hemorrhagic,  while  in  cases  where  there  is  ob- 
struction of  the  thoracic  duct  or  lacteals  a  chylous  exudation  is 
sometimes  observed  (Weiss).  Paracentesis  may  be  followed  by 
the  development  of  a  cancerous  nodule  at  the  site  of  the  puncture. 
The  peritoneal  tumours  may  be  limited  to  the  vicinity  of  the 
stomach  or  disseminated  throughout  the  abdomen.  The  former 
condition,  which  is  by  far  the  more  common,  was  observed  in  22 
per  cent,  of  our  cases,  and  the  morbid  growths  were  usually  found 
after  death  to  occupy  the  great  omentum  or  the  gastro-splenic  or 
gastro-hepatic  omentum.  In  such  cases  one  or  more  tumours 
are  detected  in  the  epigastrium,  left  hypochondrium,  or  umbilical 
region,  which  present   a  somewhat  indefinite  outline,  a  hard 


186  CANCEE  OF  THE   STOMACH 

nodular  surface,  and  a  dull  note  on  light  percussion.  At  an 
early  stage  they  move  freel}7  with  respiration,  but  at  a  later 
period  they  are  apt  to  become  fixed  by  adhesions.  Manipula- 
tion gives  rise  to  pain,  and  periodic  examinations  reveal  a 
progressive  increase  of  size.  In  most  instances  the  umbilicus 
becomes  retracted  and  fixed,  and  not  infrequently  a  cordlike 
induration  of  the  linea  alba  may  be  felt.  Diffuse  growths  of 
the  peritoneum  were  detected  during  life  in  only  2  per  cent,  of 
our  cases  of  gastric  carcinoma,  and  were  always  associated  with 
ascites.  They  chiefly  occur  in  the  region  of  the  umbilicus  or 
near  the  caecum,  where  they  give  rise  to  hard,  rounded,  tender,  and 
slightly  movable  tumours  ;  but  sometimes  the  whole  abdomen 
appears  to  be  filled  with  masses  of  various  sizes.  It  is  in  this 
condition  that  exploration  of  the  pelvis  is  of  such  importance, 
since  one  or  more  growths  may  often  be  detected  in  the  pouch 
of  Douglas  or  between  the  bladder  and  the  rectum  long  before 
a  palpable  tumour  develops  in  the  abdomen.  Miliary  car- 
cinoma never  gives  rise  to  palpable  tumours.  Thrombosis  of 
the  femoral  and  saphenous  veins,  oedema  of  the  legs,  secondary 
nodules  in  the  skin  of  the  abdomen,  and  purpuric  eruptions  are 
liable  to  ensue  during  the  course  of  the  peritoneal  disease. 

(3)  Metastases  in  the  Lung's. — These  occur  in  about  8  per 
cent,  of  all  cases,  and  are  chiefly  met  with  in  the  lower  lobes. 
In  most  instances  they  develop  at  a  late  stage  of  the  disease, 
and  are  usually,  though  not  always,  associated  with  multiple 
growths  of  the  liver.  The  special  symptoms  which  are  sup- 
posed to  ensue  from  the  pulmonary  affection  are  pain  in  the 
chest,  dyspnoea,  cough,  expectoration,  and  haemoptysis  (Darolles), 
while  examination  of  the  chest  reveals  dulness  on  percussion, 
bronchial  breathing,  and  crepitation.  As  a  matter  of  fact, 
however,  the  pulmonary  condition  is  so  often  associated  with  a 
pleural  effusion  that  its  existence  is  usually  merely  a  matter  of 
surmise. 

Carcinoma  of  the  Pleura  is  frequently  associated  with 
disease  of  the  peritoneum,  and  is  also  apt  to  occur  from 
infection  of  the  mediastinal  glands  or  the  lung.  Pleurisy  on 
the  left  side  is  often  observed  along  with  growths  of  the  cardia} 
especially  when  the  disease  has  extended  into  the  oesophagus, 
and  in  such  cases  a  haemorrhagic  effusion  is  sometimes  encoun- 
tered. Perforation  of  the  oesophagus  may  be  followed  by  pyo- 
pneumothorax or  gangrene  of  the  lung.     Blood-stained  fluid  in 


COMPLICATIONS  187 

the  right  pleura  is  usually  associated  with  disease  of  the  liver  or 
of  the  lung. 

(4)  Metastases  in  Lymphatic  Glands. — An  invasion  of  the 
gastric  lymphatic  glands  occurs  in  every  case,  but  it  is  compara- 
tively rare  for  their  enlargement  to  produce  any  special 
symptoms.  Occasionally,  however,  the  great  bulk  of  a  pyloric 
tumour  is  found  to  consist  of  cancerous  glands,  and  in  rare 
instances  an  early  infection  of  those  in  the  portal  fissure  gives 
rise  to  jaundice  or  ascites.  Disease  of  the  cceliac  glands  may 
produce  partial  obstruction  of  the  aorta  or  vena  cava,  and 
occasionally  gives  rise  to  a  palpable  tumour. 

Disease  of  the  posterior  mediastinal  glands  is  rarely  ac- 
companied by  special  symptoms,  but  occasionally  attacks  of 
spasmodic  dyspnoea,  palpitation,  or  tachycardia  ensue  from 
compression  of  the  vagi  or  sympathetic  nerves  (Mathieu). 
Metastases  situated  between  the  oesophagus  and  trachea,  below 
the  thyroid,  are  responsible  for  the  paralysis  of  the  left 
recurrent  laryngeal  nerve  which  is  sometimes  observed  (Bris- 
towe).  Enlargement  of  the  superficial  glands  has  already  been 
discussed  (p.  175). 

(5)  Metastases  in  the  Intestine. — In  the  majority  of  cases 
the  occurrence  of  intestinal  obstruction  is  due  to  direct  exten- 
sion of  the  disease  to  the  transverse  colon ;  but  in  three 
instances  which  have  come  under  our  notice  the  condition 
was  dependent  upon  malignant  stricture  of  the  ileo-csecal 
valve,  of  the  descending  colon,  or  the  rectum.  In  every 
instance  the  intestinal  symptoms  completely  masked  those 
arising  from  the  primary  complaint,  which  in  two  out  of  the 
three  cases  was  not  recognised  during  life.  It  is  possible  that 
in  many  instances  of  this  description  the  intestinal  lesion  is 
really  a  primary  growth,  and  not  a  mere  secondary  deposit 
{vide  p.  24). 

Jaundice 

This  occurs  in  about  13'7  per  cent,  of  all  cases,  and  is  most 
common  when  the  body  of  the  stomach  is  affected  or  the 
pylorus  infiltrated  without  the  production  of  a  stricture. 

In  four-fifths  of  the  cases  the  icterus  arises  from  secondary 
disease  in  the  head  of  the  pancreas,  or  from  pressure  upon  the 
hepatic  or  common  bile-duct  owing  to  an  extension  of  the  growth 
behind  the  stomach.     Metastases  in  the  liver,   portal  throm- 


188  CANCEE  OF  THE   STOMACH 

bosis,  and  septicaemia  are  chiefly  responsible  for  the  remaining 
cases. 

As  a  rule  the  icterus  develops  slowly,  and  the  skin 
gradually  acquires  the  greenish  or  black  tinge  indicative  of  a 
complete  and  permanent  block  of  the  bile  duct.  Occasionally, 
however,  its  onset  is  quite  abrupt,  and  in  rare  instances  it  is 
the  first  symptom  to  attract  attention  (Michel).  Tempo- 
rary improvement  sometimes  ensues  from  the  use  of  saline 
purgatives,  or  the  colour  of  the  skin  and  the  urine  varies 
in  intensity  from  week  to  week.  The  liver  is  invariably 
enlarged,  and  somewhat  tender  upon  pressure,  and  if  ascites  is 
present  the  fluid  is  usually  bile-stained.  The  complication 
tends  to  shorten  life  by  producing  further  impairment  of  the 
appetite  and  by  increasing  the  rapidity  of  the  emaciation.  Oc- 
casionally death  ensues  rapidly  from  a  form  of  coma  like  that 
met  with  in  acute  yellow  atrophy  of  the  liver. 

Thrombosis 

Venous  Thrombosis  is  met  with  in  about  4-5  percent,  of  all 
cases  of  carcinoma  of  the  stomach,  and  almost  invariably  occurs 
at  a  late  period  of  the  complaint,  when  the  patient  is  confined 
to  bed.  It  is  most  frequent  when  the  gastric  symptoms  are 
comparatively  latent  and  when  the  disease  is  accompanied  by 
leuchsemia. 

As  a  rule,  the  femoral,  saphenous,  or  external  iliac  veins  are 
chiefly  affected,  especially  those  of  the  left  side ;  but  sometimes 
the  thrombotic  mischief  extends  upwards  from  one  vessel  to 
another,  or  after  a  short  interval  the  corresponding  vessel  of 
the  opposite  limb  becomes  occluded.  Less  frequently  the  sub- 
clavian, axillary,  basilic,  or  external  jugulars  are  involved, 
while  in  rare  instances  thrombi  form  in  most  of  the  superficial 
veins  of  the  body  (Osier  and  McCrae).  Among  those  situated 
internally  the  inferior  vena  cava,  the  vena  portse,  the  pul- 
monary, mesenteric,  and  renal  veins  are  most  often  affected. 

Thrombosis  of  a  vein  in  a  limb  is  usually  accompanied  by 
pain,  and  followed  by  oedema  of  the  tissues  and  a  blue  coloura- 
tion of  the  skin ;  but  if  the  patient  is  extremely  asthenic  the 
process  may  be  quite  painless  and  the  swelling  only  discovered 
by  accident.  Occlusion  of  the  internal  iliac  vessels  is  some- 
times associated  with  haemorrhage  from  the  rectum. 

Portal  thrombosis  gives  rise  to  the  rapid  development  of 


COMPLICATIONS  189 

ascites,  or,  if  free  fluid  already  exists  in  the  peritoneal  cavity, 
its  quantity  is  suddenly  and  greatly  augmented.  Occasionally 
it  is  found  to  be  haernorrhagic,  and  the  patient  may  pass  bright 
blood  with  his  evacuations.  (Edema  of  the  legs  ensues  from 
pressure  of  the  fluid  upon  the  inferior  vena  cava.  Suppurative 
pylephlebitis  is  very  rare,  and  in  the  case  recorded  by  Wickham 
Legg  it  was  accompanied  by  ascites,  oedema  of  the  legs,  and  diffi- 
culty of  micturition.  Renal  thrombosis  is  indicated  by  hsema- 
turia,  pain  in  the  loin,  and  by  a  diminution  in  the  amount  of 
urine.  Pulmonary  embolism  may  ensue  from  the  detachment 
of  a  clot  from  a  peripheral  vein  or  from  the  right  side  of  the 
heart. 

Arterial  Thrombosis  is  comparatively  rare  and  chiefly  occurs 
in  the  femoral,  popliteal,  and  cerebral  vessels.  Whipham  has 
recorded  a  case  in  which  thrombosis  of  the  left  femoral  and 
popliteal  arteries  was  followed  by  gangrene  of  the  leg,  and  a 
similar  condition  of  the  liver  and  transverse  colon  has  been 
observed  from  occlusion  of  the  hepatic  and  colic  arteries 
respectively  (Cooper,  Denonvilliers,  Goullioud,  and  Mollard). 
In  a  case  of  pyloric  cancer  published  by  Flint  the  patient  was 
suddenly  attacked  by  blindness  and  paralysis  of  the  right  arm 
owing  to  thrombosis  of  the  left  middle  cerebral,  and  in 
a  similar  one  by  Merklen  there  were  right  hemiplegia,  aphasia, 
and  loss  of  sensation  on  the  affected  side. 

Venous  thrombosis  is  probably  due  to  the  altered  state  of 
the  blood  and  the  great  enfeeblement  of  the  heart  that  accom- 
pany the  later  stages  of  carcinoma  of  the  stomach.  The  greater 
liability  of  the  veins  of  the  left  leg  may  be  due  to  the  pres- 
sure exerted  upon  the  external  iliac  vein  by  an  overloaded  sig- 
moid flexure.  Thrombosis  of  both  femorals  and  iliacs  usually 
indicates  pressure  upon  the  inferior  vena  cava.  Trous- 
seau was  accustomed  to  regard  thrombosis  of  a  vein  in  the 
arm  or  leg  in  a  case  of  gastric  disease  as  pathognomonic  of 
carcinoma,  but  its  diagnostic  value  is  less  than  was  formerly 
believed.  From  the  point  of  view  of  prognosis  the  occurrence 
of  thrombosis  may  be  held  to  indicate  the  near  approach  of 
the  end,  and  the  occlusion  of  a  cerebral  vessel  as  its  immediate 
precursor. 


190  CANCER  OP  THE   STOMACH 

Secondary  Inflammations 

Certain  organs  of  the  body  are  liable  to  become  affected 
with  chronic  inflammation  independently  of  the  formation  of 
secondary  deposits  in  their  substance. 

Chronic  Gastritis,  both  parenchymatous  and  interstitial, 
invariably  accompanies  carcinoma  of  the  stomach,  and  is 
especially  severe  when  the  growth  has  given  rise  to  obstruction 
of  the  pylorus.  In  these  cases  most  of  the  early  symptoms  are 
due  to  the  inflammatory  state  of  the  viscus. 

Chronic  Enteritis  is  encountered  in  a  large  proportion  of 
the  cases,  though  it  seldom  gives  rise  to  any  special  symptoms. 
Occasionally,  however,  pain  and  diarrhoea  occur  towards  the 
termination  of  the  complaint,  and  after  death  a  few  superficial 
ulcers  are  found  in  the  colon,  or  the  intestinal  mucous  mem- 
brane presents  signs  of  diphtheritic  inflammation.  These 
conditions  are  probably  due  to  the  long-continued  retention  and 
decomposition  of  the  fseces. 

Chronic  Nephritis.— In  15  per  cent,  of  our  cases  the  kid- 
neys presented  a  granular  surface,  with  adhesion  of  the  capsule 
and  other  signs  of  interstitial  inflammation,  but  albuminuria 
existed  in  only  about  one-fifth  of  them.  Occasionally  subacute 
parenchymatous  nephritis  develops  during  the  course  of  the 
gastric  complaint,  accompanied  by  general  oedema,  anaemia, 
and  albuminuria,  and  terminates  fatally  by  pericarditis  or  ursemic 
coma.  Ursemic  convulsions  are  often  mistaken  for  evidence  of 
metastases  in  the  brain. 

Pneumonia  is  the  immediate  cause  of  death  in  about  6  per 
cent,  of  all  cases  of  gastric  cancer.  It  chiefly  occurs  during 
the  last  stage  of  the  complaint,  and  usually  exhibits  a  lobular 
distribution.  As  a  rule  its  onset  is  accompanied  by  a  sudden 
rise  of  temperature,  dyspnoea,  and  cough,  but  pain  is  seldom  a 
subject  of  complaint  and  haemoptysis  is  rarely  observed.  In 
many  instances  delirium  is  the  only  symptom.  The  temperature 
is  very  irregular  and  seldom  rises  above  103°  F.  (fig.  34,  p.  138), 
while  the  signs  of  pulmonary  consolidation  often  remain  latent. 
Death  usually  occurs  within  three  days. 

Nervous  Diseases 

(1)  Mental  Derangements. — The  depression  that  invariably 
accompanies  the  disease  is  very  liable  to  pass  into  melancholia, 


COMPLICATIONS  191 

which  may  be  attended  by  suicidal  tendencies.  Less  frequently 
delusional  insanity  develops  during  the  course  of  the  gastric 
complaint,  or  symptoms  of  acute  mania  suddenly  manifest  them- 
selves. Among  the  160  cases  recorded  by  Dittrich,  five  were 
insane  and  two  suffered  from  violent  mania. 

(2)  Cerebral  and  Spinal  Paralyses  are  met  with  in  about 
1*5  per  cent,  of  all  cases,  and  are  principally  due  to  metastases 
in  the  brain  or  spinal  cord,  thrombosis  of  vessels,  or  to  direct 
invasion  of  the  vertebral  column  by  the  morbid  growth.  Exam- 
ples of  the  latter  kind  have  been  recorded  by  Brun,  Lagrange, 
and  others,  in  which  destruction  of  the  dorsal  or  lumbar  vertebrae 
was  attended  by  an  intense  girdle  pain  and  by  partial  or  com- 
plete paraplegia. 

(3)  Peripheral  Neuritis.— In  1886  Oppenheim  and  Siemer- 
ling  drew  attention  to  the  occasional  development  of  peripheral 
neuritis  in  carcinoma  accompanied  by  profound  cachexia  ;  and 
Klippel  found  degeneration  of  the  nerves  of  the  lower  ex- 
tremities in  two  cases  of  cancer  of  the  stomach.  More  recently 
Auche  and  Miura  have  described  typical  examples  of  the 
nervous  affection  which  appeared  to  have  resulted  from  absorp- 
tion of  toxic  substances  from  the  diseased  stomach. 

(4)  Tetany. — It  was  formerly  believed  that  tetany  was 
solely  encountered  in  cases  of  pyloric  obstruction  due  to  the 
cicatrisation  of  a  simple  ulcer,  but  Trevelyan  has  recorded  an 
instance  in  which  it  attended  a  carcinomatous  stricture  of  the 
duodenum,  which  had  given  rise  to  dilatation  of  the  stomach.1 

The  principal  feature  of  this  interesting  complaint  is  the 
occurrence  of  a  tonic  spasm  affecting  the  voluntary  muscles  of 
the  body.  Its  onset  is  usually  quite  sudden,  and  often  follows 
an  attack  of  vomiting  or  diarrhoea.  In  typical  cases  the 
elbows  and  wrists  are  partially  flexed,  the  forearms  strongly 
pronated,  the  fingers  adducted  and  firmly  bent  over  the  thumbs, 
while  the  palms  are  hollowed  by  the  approximation  of  the 
thenar  and  hypothenar  eminences.  In  the  lower  limbs,  the  legs 
are  rigidly  extended,  the  soles  of  the  feet  turned  inwards,  and 
the  heels  drawn  up.  Considerable  pain  is  often  experienced 
during  the  continuance  of  the  spasm  and  the  affected  parts  are 
sometimes  cold  and  blue.  The  condition  of  the  superficial 
reflexes  is  variable  ;  but  the  deep  reflexes  are  much  exaggerated, 
and  the  muscles  react   more  readily  than  usual  to  the  inter- 

1  See  Author's  Ulcer  of  the  Stomach  and  Duodenum,  p.  311. 


192  CANCEE  OF  THE   STOMACH 

rapted  current.  Sometimes  an  attack  may  be  induced  by 
percussion  of  the  epigastrium,  by  trie  administration  of  an  enema, 
or  by  compression  of  the  main  artery  of  a  limb. 

The  other  phenomena  associated  with  this  condition  are 
neither  uniform  nor  of  great  importance.  The  pupils  are  often 
contracted  during  the  attack,  but  they  still  react  both  to  light  and 
accommodation.  Severe  headache  is  a  frequent  cause  of  com- 
plaint, and  occasionally  profuse  perspirations  are  observed. 
Betention  of  urine  occurs  in  the  majority  of  the  cases,  and 
when  the  fluid  is  drawn  off  by  a  catheter  it  is  often  found  to 
contain  a  trace  of  albumin.  Sugar  and  acetone  are  occasionally 
detected  in  it.  Cutaneous  sensibility  rarely  undergoes  any 
noticeable  alteration,  but  in  a  few  instances  temporary  hyper- 
sesthesia  or  anaesthesia  has  been  observed.  The  pulse  is  full  and 
regular,  the  breathing  quick  and  shallow,  and  the  face  and 
extremities  usually  show  signs  of  cyanosis.  The  temperature 
is  often  depressed  at  first,  but  in  fatal  cases  it  usually  rises,  and 
may  reach  109°  F.  before  death.  The  intellect  generally 
remains  unaffected. 

In  almost  every  instance  the  first  attack  is  followed  within 
a  short  time  by  several  others,  but  occasionally  the  initial  seizure 
is  separated  from  the  second  by  an  interval  of  several  weeks. 
The  actual  duration  of  the  spasm  is  also  liable  to  considerable 
variation ;  in  some  instances  it  lasts  from  five  minutes  to 
several  hours,  while  in  others  it  remains  almost  constant  for 
three  or  four  days. 

Occasionally  the  condition  of  simple  tetany  is  complicated 
by  the  occurrence  of  general  convulsions,  which  affect  the 
muscles  of  the  neck,  jaw,  back,  and  face.  The  attacks  are 
intermittent  and  last  from  a  few  minutes  to  half  an  hour,  dis- 
appearing as  suddenly  as  they  commenced,  and  leaving  the 
muscles  in  a  state  of  semi-rigidity.  During  their  continuance 
the  patient  is  unable  to  open  his  mouth  or  to  swallow,  and 
sometimes  suffers  from  opisthotonos.  This  form  of  convulsions 
must  therefore  be  regarded  as  a  species  of  tetanus.  Finally,  in 
a  small  proportion  of  the  cases  the  initial  tetany  is  followed  by 
convulsions  that  are  indistinguishable  from  epilepsy.  Gastric 
tetany  is  a  very  dangerous  complaint,  and  is  probably  always 
fatal  when  it  attacks  the  subjects  of  carcinoma.  It  appears  to  be 
due  to  the  absorption  into  the  general  circulation  of  some  toxic 
substance  generated  in  the  dilated  stomach. 


COMPLICATIONS  193 

Purpura 

A  purpuric  eruption  sometimes  accompanies  venous  throm- 
bosis, septicaemia,  or  gradual  failure  of  the  heart.  Thibierge  has 
also  described  a  hemorrhagic  eruption  which  affects  the  anterior 
surface  of  both  lower  extremities  in  a  symmetrical  manner. 
This  condition,  to  which  he  gives  the  name  of  '  cachectic 
purpura,'  is  very  rare,  and  is  followed  by  death  within  a  few  days. 
The  haemorrhages  from  the  intestine  and  the  kidney  which  are 
often  termed  '  purpuric  '  are  usually  due  to  thrombosis  of  the 
iliac  or  renal  veins. 

Septicaemia 

This  is  a  very  rare  complication,  and  is  almost  always 
associated  with  extensive  ulceration  of  the  primary  growth  or 
with  an  abscess  in  the  peritoneum  or  one  of  the  neighbouring 
organs.  In  the  majority  of  cases  it  is  characterised  by  an 
elevated  irregular  temperature,  rapid  emaciation,  and  intense 
anaemia ;  but  occasionally  abscesses  form  in  the  subcutaneous 
tissue,  pus  collects  in  the  larger  joints,  or  jaundice  develops.  In 
2'3  percent,  of  our  cases  ulcerative  endocarditis  of  the  aortic  or 
mitral  valves  was  discovered  after  death.  In  the  case  recorded 
by  Hanot  both  the  blood  and  the  contents  of  the  stomach  con- 
tained streptococci. 


194  CANCEE   OF  THE   STOMACH 


CHAPTEE   VII 

CLINICAL    VABIETIES 

The  protean  features  of  carcinoma  of  the  stoniach  afford  a 
great  temptation  to  differentiate  a  large  number  of  clinical 
varieties,  according  to  the  predominance  of  some  particular 
group  of  symptoms  or  physical  signs ;  and  however  much  one 
may  deprecate  the  growing  tendency  to  found  clinical  dis- 
tinctions on  slight  differences  of  symptomatology,  it  is  im- 
possible to  offer  an  adequate  description  of  the  disease  without 
special  allusion  to  certain  cases  that  are  attended  by  exceptional 
difficulties  of  diagnosis.  Thus,  the  general  aspect  of  the  com- 
plaint varies  to  such  a  great  extent  according  to  the  location  of 
the  neoplasm,  that  it  is  necessary  to  consider  in  detail  the 
various  symptoms  that  arise  from  obstruction  of  one  or  other 
orifice,  from  invasion  of  the  walls  or  curvatures,  and  from  a 
general  infiltration  of  the  stomach.  Again,  it  frequently 
happens  that  the  cardinal  symptoms  of  the  malady  are  either 
suppressed  or  completely  masked  by  those  which  ensue  from  the 
early  invasion  of  another  viscus,  and  it  is  therefore  convenient 
to  distinguish  a  latent  form  of  the  affection  from  those  which  are 
characterised  by  dyspepsia,  extreme  anaemia,  ascites,  or  symptoms 
of  septicaemia.  Finally,  the  precocious  development  of  gastric 
carcinoma  deserves  attention  on  account  of  its  rarity,  and  also 
the  form  which  is  engrafted  upon  a  simple  ulcer. 

(1)  Carcinoma  of  the  Cardia. — The  cardiac  third  of  the 
stomach  is  primarily  affected  in  about  10  per  cent,  of  all  cases, 
and  is  more  frequently  involved  in  men  than  in  women.  As  a  rule 
the  previous  health  has  been  extremely  good,  but  occasionally 
the  onset  of  the  disease  is  preceded  for  some  months  by  pyrosis. 
The  first  symptom  to  attract  attention  is  usually  a  difficulty  of 
swallowing,  which  is  often  attributed  to  soreness  of  the  throat  or 
to  the  ingestion  of  a  fish-bone  or  other  foreign  body ;  but  occasion- 
ally it  develops  quite  suddenly  and  without  apparent  cause.  Each 


CLINICAL  VAEIETIES 


195 


mouthful  of  solid  food  appears  to  stick  in  the  gullet,  and  degluti- 
tion is  accompanied  by  a  sense  of  uneasiness,  fulness,  or  of  actual 
pain  behind  the  lower  end  of  the  sternum.  At  the  same  time  there 
is  usually  a  complaint  of  want  of  appetite,  loss  of  flesh,  breath- 
lessness  on  exertion,  and  debility,  and  sometimes  of  attacks  of 
sharp  pain  in  the  left  side  of  the  chest  and  back.  Gradually  the 
dysphagia  increases,  until  every  attempt  to  swallow  solids  is 
accompanied  by  choking  and  regurgitation   of  the  food,  and 


- 


i. 


Fig.  48. —  Soft  ulcerating  growth  of  spheroidal-celled  carcinoma  situated  at 
the  cardiac  orifice  and  spreading  into  the  oesophagus.  (London  Hospital 
Museum.) 


even  liquids  are  rejected  unless  taken  slowly  and  in  small 
quantity.  These  phenomena  occupy  from  three  to  seven  months 
in  their  development,  at  the  end  of  which  period  the  patient 
presents  a  pallid,  careworn,  and  starved  appearance,  and  is 
found  to  have  lost  between  two  and  three  stones  in  weight. 
The  symptoms  of  the  final  stage  vary  in  different  cases.  Severe 
haemorrhage  is  rare,  but  not  infrequently  the  ejecta  consist  of 
grumous  material  or  exhibit  streaks  or  clots  of  bright  blood. 

o  2 


196  CANCEE  OF  THE   STOMACH 

In  most  instances  increasing  debility  compels  the  patient  to 
keep  his  bed,  and  he  gradually  succumbs  to  asthenia.  In 
other  cases  delirium  supervenes,  the  mouth  and  throat  are 
attacked  by  thrush,  and  death  ensues  from  exhaustion,  secondary 
pneumonia,  or  from  septic  absorption  from  the  dilated  oeso- 
phagus. Perforation  of  the  stomach  is  rare,  but  sometimes 
sloughing  of  the  oesophagus  gives  rise  to  empyema,  pneumo- 
thorax, or  gangrene  of  the  left  lung.  Occasionally  ulceration 
of  the  growth  removes  the  obstruction,  so  that  food  can  once 
more  be  swallowed  with  comparative  ease.  Death  usually 
occurs  within  nine  months. 

When  the  disease  affects  the  cardiac  region  or  the  fundus, 
without  involvement  of  the  oesophagus,  dysphagia  is  absent  and 
the  principal  symptoms  are  those  of  dyspepsia.  Pain  is  almost 
always  present,  and  is  chiefly  experienced  immediately  after  a 
meal  containing  solid  food,  but  it  may  also  be  provoked  by  hot 
liquids,  or  even  by  milk.  Vomiting  occurs  in  the  majority  of 
cases,  but  affords  little  relief  to  the  pain.  Slight  haematemesis  is 
also  a  frequent  symptom,  but  owing  to  the  integrity  of  the  pylorus 
the  blood  is  more  often  bright-red  than  altered  by  its  retention 
in  the  stomach.  Anorexia,  loss  of  flesh,  and  cachexia  are 
prominent  symptoms,  and  diarrhoea  often  alternates  with  or 
replaces  the  usual  constipation.  Life  is  rarely  prolonged  more 
than  a  year,  and  death  usually  occurs  from  exhaustion,  aggra- 
vated by  secondary  disease  of  the  liver  or  peritoneum. 

Stenosis  of  the  cardiac  orifice  may  be  recognised  by  the 
resistance  offered  to  the  passage  of  a  soft  tube  at  a  spot  about 
16-18  inches  (40-47  cms.)  from  the  incisor  teeth,  and  by  the 
evacuation  in  the  eye  of  the  instrument  of  a  small  quantity  of 
undigested  food  which  had  accumulated  above  the  stricture. 
Examination  of  the  latter  shows  it  to  consist  of  alkaline  mucus 
and  saliva,  mixed  with  milk  and  particles  of  food,  and  occa- 
sionally with  pus  or  blood  ;  while  the  microscope  reveals  the 
existence  of  salivary  corpuscles,  blood-cells,  and  sometimes 
of  small  portions  of  the  neoplasm  detached  by  ulceration. 
Auscultation  over  the  epigastrium  demonstrates  a  considerable 
delay,  or  even  suppression,  of  the  second  deglutition  sound, 
which  under  normal  circumstances  may  be  heard  in  seven  to 
twelve  seconds  after  the  patient  has  swallowed  a  mouthful  of 
fluid.  The  disease  is  rarely  accompanied  by  a  palpable  tumour, 
though  occasionally  the  contracted  stomach  forms  an  elongated 


CLINICAL  VAEIETIES 


197 


or  rounded  swelling,  which  can  be  felt  between  the  ensiform 
cartilage  and  the  left  costal  margin. 

Carcinoma  of  the  fundus  is  usually  associated  with  a  nodular 
tumour,  which  occupies  the  left  epigastrium  or  hypochondrium, 
descends  upon  inspiration,  and  is  susceptible  of  slight  lateral 
displacement.  The  stomach  itself  is  often  smaller  than  normal, 
and  in  68  per  cent,  of  the  cases  its  contents  after  a  test  meal  are 


Fig.  49. — An  enormous  ulcerated  fungoid  growth  of  cylinder-celled  carcinoma  in- 
volving the  greater  part  of  the  stomach  and  extending  into  the  oesophagus. 
(Museum  of  the  London  Temperance  Hospital.) 

found  to  be  free  from  hydrochloric  acid  and  to  exhibit  an  excess 
of  lactic  acid.  At  a  late  stage  the  omentum  and  the  left  lobe  of 
the  liver  often  present  metastases,  and  the  glands  above  the 
left  clavicle  may  become  enlarged.  When  the  disease  gives 
rise  to  a  stricture  near  the  centre  of  the  organ,  the  symptoms 
resemble  those  of  pyloric  stenosis,  and  examination  shows 
considerable  dilatation  of  the  fundus  without  a  palpable  tumour. 


198 


CANCEE  OF  THE   STOMACH 


Sizzling  and  gurgling  sounds  may  sometimes  be  heard  over  the 
epigastrium. 

(2)  Carcinoma  of  the  Body  (Walls  and  Curvatures). — 

Growths  which  affect  the  central  region  of  the  stomach  are 
usually  extensive,  of  soft  consistence,  and  of  rapid  growth,  and 
are  consequently  accompanied  by  numerous  symptoms  and 
important  physical  signs.  Pain  is  experienced  in  the  majority 
of  the  cases,  and  is  usually  increased  by  food,  while  sloughing 
of  the  growth  or  implication  of  the  peritoneum  often  gives  rise 
to  acute  and  continuous  suffering.     Vomiting  is  an  inconstant 


Fig.  50. —  Stomach  viewed  from  behind,  showing  enormous  infiltration  of  its  walls 
with  soft  spheroidal-celled  carcinoma,  and  its  cavity  almost  obliterated  by  a 
cauliflower  growth.     (London  Hospital  Museum.) 

phenomenon,  and  chiefly  occurs  during  the  periods  of  digestion 
or  in  the  early  morning.  Nausea  and  retching  are  common 
sources  of  complaint,  and  anorexia,  loss  of  flesh,  and  cachexia 
are  invariably  present.  Efeniatemesis  is  frequent  but  variable 
in  quantity,  a  coffee-ground  appearance  of  the  vomit  indicating 
oozing  from  the  surface  of  the  neoplasm,  while  the  ejection  of 
bright  blood  is  usually  associated  with  ulceration  of  the  growth. 
Fatal  haemorrhage  may  ensue  from  the  destruction  of  a  large 
artery,  and  general  or  local  peritonitis  from  perforation  of  the 
coats  of  the  stomach.  When  metastases  develop  in  the  liver 
or  peritoneum  at  an  early  period,  the  symptoms  due  to  the 


CLINICAL  VAEIETIES  199 

primary  disease  often  diminish  or  even  subside.  In  many 
cases  there  is  an  elevation  of  temperature.  Death  usually 
takes  place  from  exhaustion  within  twelve  months,  and  in  only 
about  13  per  cent,  is  life  prolonged  for  more  than  a  year. 

A  palpable  tumour  exists  in  about  81  per  cent,  of  the  cases, 
and  usually  occupies  the  epigastric,  umbilical,  or  left  hypo- 
chondriac region.  It  presents  a  nodular  surface,  an  indefinite 
outline,  a  dull  note  on  light  percussion,  and  is  movable  by 
palpation  and  with  respiration.  Examination  shows  that  the 
stomach  is  moderately  dilated,  and  that  its  contents  are  free 
from  hydrochloric  acid.  Small  particles  of  the  neoplasm  or  cells 
showing  atypical  mitoses  may  be  extracted  by  a  tube,  and  the 
Oppler-Boas  bacillus  often  accompanies  the  signs  of  lactic  acid 
fermentation.  Thrombosis  of  the  veins  of  the  lower  extremities 
and  metastases  in  the  abdominal  wall  are  not  infrequent. 

(3)  Carcinoma  of  the  Pylorus. — Disease  of  this  part  of  the 
stomach  constitutes  about  60  per  cent,  of  all  the  cases.  The 
initial  symptoms  are  usually  those  of  indigestion,  and  for  several 
months  the  chief  complaint  may  be  flatulence  and  distension 
after  meals,  acidity,  constipation,  loss  of  appetite,  and  emacia- 
tion. In  every  instance  vomiting  occurs  sooner  or  later,  and 
although  at  first  it  may  only  be  occasional,  and  afford  temporary 
relief  to  the  other  symptoms,  it  gradually  increases  in  frequency 
until  it  is  repeated  once  or  twice  each  day.  The  ejecta  are 
considerable  in  quantity,  and  consist  of  a  sour-smelling  fluid,  in 
which  undigested  articles  of  food  may  be  recognised  which  were 
eaten  some  days  previously.  From  time  to  time  an  extreme 
degree  of  gastric  intolerance  is  apt  to  develop  from  intercurrent 
gastritis,  accompanied  by  incessant  retching  and  vomiting  of 
mucus.  Pain  is  rarely  severe  until  the  growth  has  undergone 
ulceration,  when  great  suffering  may  be  experienced,  either  con- 
tinuously or  within  half  an  hour  after  food.  Anorexia  is  usually 
pronounced,  the  tongue  is  foul,  the  bowels  are  confined,  and  the 
pulse  is  of  low  tension.  Profuse  hsematemesis  is  comparatively 
rare,  but  both  the  vomit  and  the  contents  of  the  stomach 
extracted  by  a  tube  frequently  contain  small  quantities  of 
altered  blood.  The  duration  of  life  varies  in  different  cases, 
fatal  exhaustion  usually  ensuing  within  nine  months  when  the 
pyloric  obstruction  is  severe,  while  life  may  be  prolonged  for 
more  than  twice  that  period  if  the  orifice  is  only  slightly 
affected.  Extension  of  the  growth  along  the  great  curvature 
may  produce  obstruction  of  the  colon  or  a  fistula. 


200 


CANCEE  OF  THE   STOMACH 


The  chief  sign  of  the  disease  consists  of  dilatation  and 
hypertrophy  of  the  stomach,  which  may  be  recognised  by 
visible  peristalsis,  by  stagnation  of  the  food,  and  by  a  notable 
enlargement  of  the  viscus  on  artificial  inflation.  Free  hydro- 
chloric acid  disappears  at  an  early  period  in  the  vast  majority  of 
the  cases,  and  is  replaced  by  an  excess  of  lactic  and  other 
organic  acids.  The  Oppler-Boas  bacillus,  torulse,  sarcinse,  and 
other  micro-organisms  may  be  recognised  in  the  gastric  contents, 
and  the  sulphocyanide  of  potassium  in  the  saliva  is  greatly 
reduced  in  quantity.  In  about  71  per  cent,  of  the  cases  a 
tumour  may  be  detected  in  the  epigastric,  umbilical,  or  right 


Fig.  51. — Scirrhous  carcinoma  of  the  pylorus  causing  stenosis. 
(London  Hospital  Museum.) 

hypochondriac  region,  which  is  of  an  oval  or  round  shape, 
movable  with  respiration,  and  often  capable  of  being  displaced 
by  the  hand.  Distension  of  the  stomach  displaces  the  tumour 
to  the  right,  and  when  the  organ  is  greatly  dilated  and  the 
growth  non-adherent  to  the  liver  the  traction  of  the  heavy 
viscus  may  drag  the  tumour  into  the  lower  part  of  the  abdomen. 
Secondary  deposits  in  the  liver  or  peritoneum  rarely  coexist 
with  severe  stenosis  of  the  pylorus. 

(4)  Total  Infiltration  of  the  Stomach. — This  condition 
is  very  rare,  and  is  met  with  in  less  than  3  per  cent,  of  all  cases. 
When  the  morbid  growth  is  fibrous  in  character  the  stomach 


CLINICAL  VAEIETIES  201 

becomes  greatty  reduced  in  size  and  presents  the  appearance  of 
a  leather  bottle ;  but  the  soft  spheroidal-  and  cylindrical-celled 
carcinornata  produce  a  greater  thickening  of  the  gastric  wall  with 
a  lesser  diminution  of  lumen.  In  the  former  case  the  disease 
may  run  a  protracted  course,  and  is  often  unaccompanied  by 
metastases,  while  in  the  latter  death  occurs  at  an  earlier  period, 
and  is  usually  accelerated  by  secondary  growths  of  the  perito- 
neum or  liver. 

For  several  months  the  chief  symptoms  consist  of  discom- 
fort, flatulence,  and  distension  after  meals,  with  anorexia,  loss 
or  flesh,  debility,  anasmia,  and  constipation.  As  soon  as  the 
greater  part  of  the  stomach  has  been  involved,  or  one  of  the 
orifices  is  contracted,  vomiting  becomes  the  most  prominent 
feature,  and  increases  in  severity  until  the  end.  At  first  it 
chiefly  ensues  after  the  ingestion  of  an  unusually  large  meal, 
when  the  patient  feels  that  he  has  overtaxed  the  capacity  of 
his  stomach  and  rejects  the  surplus  amount  as  an  infant  does 
under  similar  circumstances.  Gradually  the  quantity  of  food 
has  to  be  reduced,  until  less  than  six  fluid  ounces  can  be 
swallowed  without  producing  regurgitation.  About  this  period 
attacks  of  acute  gastritis  are  apt  to  supervene,  and  to  give  rise  to 
continuous  retching  and  vomiting,  which  prevent  the  adminis- 
tration of  food  by  the  mouth.  When  these  acute  symptoms 
subside  the  general  health  is  found  to  have  greatly  deteriorated 
and  the  power  of  absorption  to  be  much  impaired.  The  final 
stage  of  the  disease  is  characterised  by  the  regurgitation  of  food 
immediately  after  it  has  been  swallowed,  and  a  complete  in- 
ability to  partake  of  solids.  These  symptoms  so  closely 
resemble  those  that  ensue  from  obstruction  of  the  oesophagus 
that  they  frequently  lead  to  an  erroneous  diagnosis. 

In  some  cases  the  symptoms  are  gradually  engrafted  upon 
those  of  pyloric  stenosis,  owing  to  the  extension  of  what  was 
originally  a  localised  growth.  In  these  circumstances  the 
periodic  vomiting  becomes  more  frequent,  more  immediately 
dependent  upon  the  ingestion  "of  food,  and  less  profuse,  until 
the  amount  of  nourishment  that  can  be  taken  becomes  greatly 
reduced  and  regurgitation  occurs  immediately  after  swallowing. 
When  a  growth  that  originally  obstructed  the  cardia  progres- 
sively involves  the  walls  of  the  stomach  until  it  produces  a 
general  contraction  of  the  organ,  the  initial  dysphagia  and  regur- 
gitation continue  throughout  the  whole  course  of  the  complaint. 


202 


CANCEE  OF  THE   STOMACH 


Pain  is  chiefly  experienced  when  the  mucous  membrane 
undergoes  superficial  ulceration  or  the  serous  coat  becomes 
inflamed  and  adherent  to  the  surrounding  organs.  In  the 
former  case  the  ingestion  of  solid  food,  or  even  milk,  gives  rise 
to  an  aching  or  burning  sensation  at  the  epigastrium,  which 
is  relieved,  though  not  removed,  by  vomiting ;  while  in  the 
latter  constant  and  severe  pain  develops  without  obvious  cause, 
and  continues  with  a  varying  intensity  for  many  weeks. 


Fig.  52. — A  stomach  viewed  from  behind,  showing  diffuse  infiltration  by  scirrhous 
carcinoma,  with  enlarged  glands  along  the  curvatures.  (Museum  of  the  Royal 
College  of  Surgeons.) 

Cachexia  is  a  marked  symptom  when  pain  is  the  pre- 
dominant feature  of  the  complaint,  and  is  usually  attributed 
to  exhaustion.  It  may  often  be  observed,  however,  that  the 
vomit  constantly  contains  small  quantities  of  altered  blood,  or 
that  signs  of  haemorrhage  are  unexpectedly  discovered  when 
the  stomach  is  emptied  by  a  tube.  The  duration  varies  ac- 
cording to  the  rapidity  of  infiltration  and  the  degree  of  contrac- 
tion of  the  stomach.  Of  the  cases  we  collected  from  different 
sources  the  average  was  ten  months,  while  of  those  contained 


CLINICAL  VAEIETIES  203 

in  our  own  series  50  per  cent,  lived  more  than  a  year  and 
12  per  cent,  more  than  eighteen  months. 

The  Physical  Signs  differ  somewhat  from  those  of  the  other 
varieties  of  the  disease.  Instead  of  presenting  evidences  of 
dilatation,  the  stomach  becomes  progressively  smaller,  and 
towards  the  termination  of  the  complaint  may  be  quite  ob- 
scured by  the  intestines.  Owing  to  rigidity  of  the  gastric 
walls  it  is  impossible  to  inflate  the  organ,  and  the  gas  that  is 
introduced  immediately  escapes  into  the  oesophagus  or  bowel. 
The  employment  of  a  tube  is  apt  to  confuse  rather  than  to  aid 
the  diagnosis,  since  the  contracted  state  of  the  stomach  offers 
resistance  to  the  passage  of  the  instrument,  and  consequently 
may  simulate  a  stricture  of  the  oesophagus.  It  may  usually  be 
observed,  however,  that  the  apparent  stricture  is  situated  at  a 
distance  greater  than  eighteen  inches  from  the  incisor  teeth, 
and  that  the  fluid  extracted  is  acid  in  reaction.  After  the  ad- 
ministration of  a  test  meal  only  a  small  quantity  of  material 
can  be  withdrawn,  and  from  the  filtrate  both  free  hydrochloric 
and  lactic  acids  are  found  to  be  absent.  "When  vomiting  is 
excessive  the  gastric  fluid  is  usually  alkaline.  In  about  one 
third  of  the  cases  a  rounded  irregular  or  elongated  tumour  may 
be  detected  in  the  epigastrium  or  left  hypochondrium,  which 
moves  with  respiration  and  may  sometimes  be  felt  to  harden 
and  relax  alternately  when  grasped  by  the  hand. 

(5)  The  Latent  Form. — Cases  are  occasionally  encountered 
in  which  the  symptoms  are  either  entirely  absent  or  only  appear 
at  a  late  stage  of  the  complaint.  Three  types  of  latency  may  be 
observed :  (a)  Where  gastric  symptoms  are  completely  in  abe}T- 
ance  ;  (b)  Where  they  are  replaced  by  those  due  to  the  cachexia 
or  to  some  coexisting  disease ;  (c)  Where  they  are  masked  by 
those  arising  from  cancerous  infection  of  other  organs. 

(a)  A  complete  absence  of  symptoms  is  very  rare,  and  is 
chiefly  met  with  in  old  people  who  are  physically  or  mentally 
feeble.  In  such  the  sole  indication  of  disease  consists  of  general 
decay,  associated  with  loss  of  flesh,  anaemia,  anorexia,  constipa- 
tion, and  debility,  and  perhaps  with  flatulence  and  distension 
after  meals.  These  symptoms  steadily  progress  until  the 
patient  is  obliged  to  take  to  his  bed,  when  life  slowly  and  almost 
imperceptibly  ebbs  away.  In  other  instances  sudden  perfora- 
tion (Watson),  haematemesis  (Surmont  and  Patoir),  or  haemor- 
rhage from  the  bowel  (Caven)  occurs,  and  constitutes  the  first 


204  CANCEE  OP  THE  STOMACH 

and  only  indication  of  a  gastric  lesion ;  while  occasionally  a 
casual  examination  of  the  abdomen  reveals  the  existence  of  a 
large  tumour  of  the  stomach,  the  presence  of  which  had  been 
entirely  unsuspected.  Thus,  Siredey  relates  a  case  in  which  a 
cancerous  mass  involving  the  pylorus  and  the  greater  curvature 
existed  without  any  symptoms,  while  in  the  similar  one  recorded 
by  Kepler  the  tumour  was  so  movable  that  it  was  regarded  as 
a  floating  spleen.  In  the  following  case  the  disease  ran  its 
course  without  exciting  any  suspicion  of  its  presence. 

Case  VI.  We  attended  the  autopsy  of  an  elderly  gentleman 
who  was  supposed  to  have  died  from  some  mysterious  disorder  of 
nutrition.  For  nearly  a  year  he  had  progressively  but  slowly  lost 
flesh,  and  had  become  feeble,  lacking  in  mental  and  physical  energy, 
and  very  despondent.  There  had  never  been  any  pain,  discomfort 
after  food,  vomiting,  or  other  indication  of  disease  of  the  stomach,  nor 
could  any  abnormal  physical  signs  be  detected  in  the  various  organs 
of  the  body.  Death  had  occurred  very  gradually  from  exhaustion. 
Upon  opening  the  stomach  an  ulcerated  carcinomatous  growth, 
measuring  three  inches  by  two,  was  found  upon  the  posterior  surface 
near  the  pylorus.  The  glands  along  the  lesser  curvature  were 
enlarged,  and  numerous  small  nodules  were  scattered  through  the 
substance  of  the  liver. 

(b)  The  presence  of  organic  disease  in  some  other  impor- 
tant organ  of  the  body  is  not  only  apt  to  mask  the  symptoms 
arising  from  carcinoma  of  the  stomach,  but  by  the  promi- 
nence of  its  physical  signs  may  distract  attention  from  those 
that  accompany  the  malignant  complaint.  Thus,  in  the  case 
of  a  patient  who  suffers  from  cough  and  expectoration,  and  who 
presents  the  indications  of  lung  disease,  any  complaint  of 
debility,  want  of  appetite,  indigestion,  or  loss  of  flesh,  will 
be  ascribed  without  hesitation  to  the  pulmonary  mischief ;  while 
the  existence  of  general  oedema  with  albuminuria,  or  of  anaemia 
with  venous  thrombosis,  will  naturally  direct  attention  to  the 
state  of  the  kidneys  or  the  blood  rather  than  to  that  of  the 
digestive  organs.  It  consequently  happens  that  under  these 
and  similar  circumstances  carcinoma  of  the  stomach  may  run 
its  entire  course  without  exciting  the  least  suspicion  of  its 
existence  in  the  mind  of  the  patient  or  his  medical  attendant. 

Case  VII.  Phthisis  :  pleurisy,  with  effusion  and  thrombosis  of  the 
right  common  iliac  vein,  with  latent  cancer  of  the  stomach.  A  woman, 
thirty-seven  years  of  age,  was  admitted  into  hospital  for  severe  cough 


CLINICAL  VAEIETIES  205 

and  expectoration  of  ten  months'  duration.  She  stated  that  during 
her  illness  she  had  lost  more  than  a  stone  in  weight,  had  become 
much  debilitated,  and  had  had  frequent  attacks  of  haemoptysis,  but, 
with  the  exception  of  a  certain  amount  of  flatulence  after  meals,  had 
not  suffered  from  symptoms  of  disordered  digestion.  Examination 
showed  consolidation  of  the  upper  lobe  of  the  right  lung,  with  pleuritic 
effusion  upon  the  same  side.  The  temperature  was  elevated  at  night 
and  subnormal  in  the  morning.  Six  days  after  admission  she  was 
attacked  with  pain  in  the  left  side  of  the  chest,  and  a  loud  friction 
sound  became  audible  over  the  base  of  the  lung.  A  week  later  she 
complained  of  severe  pain  in  the  right  foot,  and  this  was  followed  by 
oedema,  coldness,  and  pallor  of  the  leg  and  thigh.  The  patient  rapidly 
lost  strength  and  succumbed  at  the  end  of  six  weeks.  A  post-mortem 
examination  showed  extensive  tubercular  disease  of  the  right  lung, 
with  recent  pleurisy  at  the  left  base.  About  one  inch  from  the 
pylorus,  on  the  posterior  wall  of  the  stomach,  there  was  a  carcino- 
matous growth  about  the  size  of  half  a  crown,  which  had  given  rise 
to  enlargement  of  the  glands  above  the  pancreas  and  had  produced 
several  small  metastases  in  the  liver.  The  right  femoral  and  common 
iliac  veins  were  occluded  by  a  thrombus. 

Case  VIII.  General  oedema :  albuminuria  and  pleurisy  with 
latent  cancer  of  the  stomach.  A  man  aged  fifty-four  was  admitted 
into  hospital  for  swelling  of  the  legs.  According  to  his  history  he 
had  suffered  from  inflammation  of  the  kidneys  five  years  before,  and 
had  since  been  liable  to  asthma,  headache,  and  vomiting  in  the  earlv 
morning.  The  appetite  remained  fair,  the  bowels  were  regular,  and 
no  pain  or  discomfort  .was  experienced  after  meals.  The  legs,  thighs, 
back,  and  face  were  found  to  be  cedematous,  and  the  abdomen  was 
distended  with  fluid,  but  neither  tumour  nor  tenderness  could  be 
detected.  There  were  signs  of  chronic  bronchitis  and  of  effusion  into 
the  right  pleural  cavity.  The  urine  was  much  reduced  in  quantity 
and  contained  a  large  amount  of  albumin  and  many  fatty  and 
granular  casts.  Death  ensued  from  uraemia  within  a  few  days.  A 
necropsy  showed  that,  in  addition  to  chronic  parenchymatous  nephritis, 
almost  the  whole  of  the  stomach  was  affected  by  a  cancerous  growth, 
which  had  contracted  the  organ  and  given  rise  to  metastases  in  the 
peritoneum  and  liver. 

Case  IX.  Cardiac  disease  :  no  gastric  symptoms,  but  a  palpable 
tumour  of  the  stomach.  A  woman,  fifty  years  of  age,  was  admitted 
into  the  London  Temperance  Hospital  on  account  of  urgent  dyspnoea 
and  oedema  of  the  legs.  She  had  suffered  from  rheumatic  fever  in 
early  life,  but  had  enjoyed  good  health  until  five  months  previously, 
when  she  began  to  experience  shortness  of  breath  upon  exertion  and 
to  lose  flesh.  She  had  never  had  any  pain  after  meals,  but  occasion- 
ally complained   of   nausea  in  the  early  morning   and    exhibited  a 


206  CANCEE  OF  THE   STOMACH 

strong  distaste  for  food.  On  examination  the  heart  was  found  to  be 
much  dilated,  and  both  the  mitral  and  aortic  valves  were  obviously 
incompetent.  The  liver  was  enlarged  and  tender,  and  the  abdomen 
was  distended  with  fluid.  Treatment  directed  to  the  state  of  the  heart 
led  to  considerable  improvement,  and  a  diminution  of  the  ascites 
permitted  the  detection  of  a  round  and  somewhat  painful  tumour 
situated  immediately  above  and  to  the  left  of  the  navel.  This  mass 
increased  in  size  and  became  the  seat  of  occasional  shooting  pains, 
but  there  were  no  gastric  symptoms.  Death  ensued  quite  suddenly 
from  syncope.  Post-mortem  examination  showed  that  the  great 
curvature  of  the  stomach  was  affected  by  a  carcinomatous  growth 
which  had  partially  invaded  the  transverse  colon. 

(c)  It  is  a  common  clinical  observation  that  a  rapid  involve- 
ment of  the  liver  usually  masks  the  symptoms  of  the  primary 
growth  in  the  stomach,  which  is  often  found  after  death  to  be 
quite  inconsiderable  in  size  and  may  even  have  undergone  partial 
cicatrisation.  In  such  cases  severe  pain  and  vomiting  after 
meals  are  usually  absent,  and  the  patient  merely  complains  of 
nausea,  distension,  and  flatulence.  On  the  other  hand,  the 
hepatic  affection  is  accompanied  by  constant  pain  in  the 
epigastrium  or  right  side  of  the  chest,  ascites,  cachexia,  emacia- 
tion, and  sometimes  by  jaundice.  The  disease  runs  its  course 
in  five  to  seven  months,  and  in  the  absence  of  a  necropsy  the 
patient  is  usually  supposed  to  have  died  from  primary  cancer 
of  the  liver.  The  frequency  with  which  this  mistake  is  made 
is  indicated  by  the  fact  that  nearly  one  third  of  all  cases  which 
are  diagnosed  as  '  cancer  of  the  liver '  are  found  after  death  to 
present  a  primary  growth  in  the  stomach. 

Occasionally  a  patient  will  seek  advice  solely  on  account  of 
symptoms  arising  from  metastases  in  the  lungs,  pleurae,  bones, 
lymphatic  glands  above  the  clavicle,  or  even  from  multiple 
growths  in  the  skin.  In  the  following  case  all  the  symptoms 
pointed  to  a  primary  tumour  of  the  brain,  and  no  suspicion  of 
malignant  disease  of  the  stomach  was  entertained. 

Case  X.  Latent  cancer  of  the  stomach  with  a  secondary  growth 
in  the  brain.  A  man,  fifty-seven  years  of  age,  was  admitted  into 
hospital  for  paralysis  of  the  right  arm.  It  appeared  from  his  history 
that  three  months  before  he  had  fallen  down  in  a  fit,  after  which  the 
arm  had  become  weak  and  had  sometimes  been  attacked  with 
trembling.  He  had  also  suffered  from  persistent  headache,  giddiness, 
and  occasionally  from  nausea,  but  there  had  been  no  vomiting. 
Examination  allowed  much  weakness  of  the  right  hand  and  forearm, 


CLINICAL  VAEIETIES  207 

with  slight  wasting  of  the  muscles.  There  was  also  well-marked 
double  optic  neuritis.  Death  occurred  suddenly  about  a  fortnight 
later.  At  the  necropsy  the  pylorus  was  found  to  be  adherent  to  the 
under  surface  of  the  liver,  and  presented  on  its  inner  surface  a  large 
ragged  cancerous  growth,  which  had  given  rise  to  a  few  secondary 
deposits  in  the  liver.  There  was  a  secondary  nodule  in  the  posterior 
part  of  the  corpus  callosum  on  the  left  side,  with  recent  haemorrhage 
into  its  substance. 

(6)  The  Ascitic  Form. — In  this  variety  an  abundant  exuda- 
tion of  fluid  takes  place  into  the  peritoneal  cavity,  which  masks 
the  signs  and  symptoms  of  the  primary  lesion  and  gives  rise  to 
considerable  difficulty  of  diagnosis.  In  the  great  majority  of 
cases  the  effusion  is  due  to  secondary  carcinosis  of  the  peri- 
toneum, but  occasionally  it  may  arise  from  the  pressure  exerted 
by  a  nodule  of  growth  or  an  enlarged  gland  upon  the  portal 
vein.  The  following  examples  serve  to  illustrate  the  symptoms 
presented  by  cases  of  this  description. 

Case  XI.  A  woman,  fifty-three  years  of  age,  was  admitted 
into  hospital  under  our  care  for  ascites.  She  stated  that  about  two 
months  previously  she  had  noticed  a  sensation  of  weight  and  fulness 
in  the  abdomen,  which  was  somewhat  increased  after  meals,  and  gave 
rise  to  difficulty  of  breathing.  Within  the  course  of  a  week  or  two 
the  body  began  to  swell  and  the  dyspnoea  became  greatly  aggravated. 
She  had  never  suffered  from  pain  or  vomiting  after  food,  but  had 
latterly  lost  a  great  deal  of  flesh  and  had  grown  very  weak.  On 
examination  the  abdomen  was  found  to  be  greatly  distended,  and  there 
was  some  enlargement  of  the  superficial  veins.  There  was  a  well- 
marked  thrill  on  palpation,  but  the  percussion-note  was  dull  all  over 
and  no  evidence  of  floating  intestine  could  be  detected.  Owing  to 
the  urgency  of  the  symptoms,  paracentesis  was  performed,  and  246 
ounces  of  clear  fluid  were  withdrawn.  Palpation  then  revealed  a 
hard  nodular  tumour  of  oblong  shape,  which  was  situated  across 
the  epigastrium,  about  an  inch  above  the  navel,  and  was  slightly 
movable  with  respiration.  There  was  no  enlargement  of  the  liver 
or  other  indication  of  visceral  disease.  Three  days  later  the  fluid  had 
re-accumulated  and  tapping  was  again  performed,  but  the  patient 
rapidly  sank  and  died  from  cardiac  failure  within  a  week. 

Necropsy.  The  peritoneum  was  covered  with  small  circumscribed 
masses  of  carcinoma,  which  varied  from  tbe  size  of  a  millet-seed  to 
that  of  a  pea.  The  great  omentum  was  infiltrated,  and  formed  a 
sausage-shaped  roll  across  the  anterior  surface  of  the  stomach,  to  which 
it  was  adherent.  Situated  upon  the  posterior  wall  of  the  stomach, 
near  the  carclia,  was  a  large  ulcerated  growth,  which  had  extended 
into  the  substance  of  the  pancreas.     The  other  viscera  were  healthy. 


208  CANCEE  OF  THE   STOMACH 

It  will  be  observed  that  in  the  foregoing  case  the  patient 
complained  solely  of  distension  of  the  abdomen  with  difficulty 
of  breathing,  and  had  never  suffered  from  any  symptom  indi- 
cative of  cancer  of  the  stomach.  It  may  therefore  be  concluded 
that  the  gastric  complaint  had  remained  latent  until  the  inva- 
sion of  the  peritoneum  had  given  rise  to  ascites.  In  the  next 
case  the  peritoneal  effusion  was  preceded  by  sufficient  gastric 
disturbance  to  permit  of  an  accurate  diagnosis  being  made 
during  life. 

Case  XII.  A  man,  forty-one  years  of  age,  stated  that  for  two 
months  he  had  suffered  from  pain  after  meals,  flatulence,  and 
oppression  at  the  chest.  He  had  also  vomited  occasionally,  but  had 
never  brought  up  any  blood.  The  indigestion  had  been  accompanied 
by  loss  of  appetite  and  progressive  debility,  but  he  did  not  think  that 
he  had  lost  much  flesh.  A  week  before  he  came  to  the  hospital  he 
had  been  suddenly  seized  with  stabbing  pain  in  the  abdomen,  which 
caused  him  to  feel  sick  and  ill,  after  which  the  stomach  began  to 
swell.  On  admission  the  abdomen  was  uniformly  enlarged,  and  the 
superficial  veins  were  more  prominent  on  the  right  than  on  the  left 
side.  When  he  lay  upon  his  back  the  signs  of  ascites  were  very 
obvious,  but  percussion  over  the  umbilical  region  elicited  a  dull  note 
instead  of  the  tympanitic  resonance  due  to  floating  intestine.  It  was 
also  observed  that  the  right  loin  was  dull  posteriorly,  while  on  the 
left  side  the  percussion-note  was  resonant  from  the  lower  ribs  to  the 
crest  of  the  ilium.  No  tumour  could  be  felt  even  after  the  evacuation 
of  several  pints  of  fluid.  Although  paracentesis  afforded  considerable 
relief,  the  patient's  strength  rapidly  failed,  and  he  died  at  the  end  of 
six  weeks. 

Necropsy.  There  was  considerable  ascites  present.  The  colon, 
small  intestines,  great  omentum,  and  stomach  were  united  into  a  mass 
which  was  attached  to  the  spine  on  the  left  side.  The  whole  of  the 
peritoneum  was  much  thickened  and  covered  with  miliary  carcinoma. 
The  stomach  was  contracted  and  its  walls  greatly  thickened  by 
scirrhous  infiltration,  but  the  pylorus  was  not  affected  nor  was  the 
mucous  membrane  ulcerated. 

Among  the  clinical  records  of  the  London  Hospital  of  the 
last  twenty  years  we  have  discovered  fourteen  cases  in  which 
ascites  constituted  the  sole  indication  of  cancer  of  the  stomach. 
In  six  of  these  progressive  enlargement  of  the  abdomen, 
followed  by  oedema  of  the  legs,  was  the  first  symptom  to 
attract  the  attention  of  the  patient ;  in  six  the  ascites  had 
been  preceded  for  a  month  or  two  by  pain  or  discomfort  after 


CLINICAL  VAEIETIES  209 

meals,  flatulence,  and  vomiting ;  while  in  the  remaining  two 
the  gastric  and  peritoneal  symptoms  appeared  to  develop  at  the 
same  time.  It  may  therefore  be  concluded  that  in  at  least 
one  half  of  all  cases  there  is  no  evidence  to  connect  the  ascites 
with  a  malignant  growth  of  the  stomach. 

As  the  disease  progressed  pain  and  distension  of  the  abdomen, 
accompanied  by  shortness  of  breath  and  palpitation,  were  invari- 
ably present,  but  only  in  one  third  of  the  cases  was  there  any 
complaint  of  pain  after  food  or  vomiting.  The  temperature  was 
subnormal  in  every  instance  except  one,  where  the  peritonitis 
was  ushered  in  with  slight  fever.  A  palpable  tumour  existed 
in  four  cases,  and  in  each  instance  it  was  found  to  be  due  to 
infiltration  of  the  great  omentum.  In  the  remainder  the  peri- 
toneum was  affected  with  miliary  cancer,  and  the  stomach  was 
situated  too  deeply  to  be  detected  by  palpation.  Effusion  into 
the  pleura  occurred  in  one  third  of  the  cases,  and  was  more 
frequent  on  the  left  than  on  the  right  side.  In  one  case  the 
pericardium  became  inflamed  immediately  before  death.  In 
every  instance  the  ascites  was  considerable  in  amount,  recurred 
rapidly  after  paracentesis,  and  as  a  rule  the  contraction  of  the 
mesentery  caused  the  intestines  to  be  covered  by  fluid,  so  that 
the  anterior  aspect  of  the  abdomen  was  dull  instead  of  resonant 
on  percussion.  Occasionally  adhesion  of  the'  bowel  to  the 
spine  or  the  kidney  gave  rise  to  a  tympanitic  note  over  the 
lumbar  region.  Cases  of  this  description  run  their  course  with 
great  rapidity,  for  we  find  that  the  average  duration  of  life  in 
those  of  our  series  was  only  seventeen  weeks. 

(7)  The  Dyspeptic  Form. — This  occupies  an  intermediate 
position  between  the  latent  and  the  ordinary  varieties  of  the 
disease.  It  is  characterised  by  the  presence  of  dyspeptic 
symptoms  resembling  those  of  an  inflammatory  or  nervous 
affection  of  the  stomach,  which  no  form  of  treatment  will 
relieve  and  which  are  accompanied  by  progressive  loss  of  flesh 
and  strength.  Pain  after  food  is  rarely  complained  of,  but 
there  is  a  constant  sense  of  uneasiness,  discomfort,  or  distension, 
which  is  increased  by  liquid  as  well  as  solid  food,  and  is 
attended  by  anaemia  and  obstinate  constipation.  Nausea  is 
often  present  in  the  early  morning  or  after  meals,  but  vomiting 
seldom  occurs  and  hsematemesis  is  exceptional.  At  a  late 
stage  of  the  complaint,  however,  a  small  quantity  of  altered 
blood  may  sometimes  be  extracted  from  the  stomach.      Ex- 

p 


210  CANCEE  OF  THE   STOMACH 

animation  of  the  gastric  contents  after  a  test  meal  shows  a 
marked  deficiency  or  entire  absence  of  free  hydrochloric  acid, 
but  lactic  acid  may  not  exist  until  shortly  before  death.  Care- 
ful examination  usually  reveals  a  moderate  degree  of  dilatation 
of  the  stomach,  and  not  infrequently  a  tumour  in  the  region  of 
the  pylorus.  Owing  to  the  insidious  nature  of  the  complaint, 
life  is  often  prolonged  for  a  considerable  period,  and  we  have 
met  with  several  cases  where  the  persistent  and  progressive 
character  of  the  symptoms  seemed  to  indicate  a  duration  of 
three  or  four  years.  In  other  instances  involvement  of  the 
pylorus  or  cardiac  orifice  by  the  growth  leads  to  the  develop- 
ment of  periodic  vomiting  'or  dysphagia,  which  soon  brings  life 
to  an  end. 

It  is  worthy  of  notice  that  the  occurrence  of  pregnancy 
almost  invariably  gives  rise  to  excessive  vomiting,  which  no 
treatment  will  allay,  and  which  does  not  subside  even  after  the 
induction  of  abortion. 

(8)  The  Anaemic  Form. — It  has  long  been  known  that 
certain  cases  of  carcinoma  of  the  stomach  are  attended  from 
an  early  period  by  an  extreme  degree  of  anaemia,  the  symptoms 
of  which  take  precedence  of  those  arising  from  the  gastric  lesion 
and  occasion  considerable  difficulties  in  diagnosis.  A  careful 
consideration  of  the  various  cases  of  this  description  which 
have  come  under  our  notice  has  convinced  us  that  at  least 
three  varieties  of  anaemia  may  accompany  the  onset  of  the 
malignant  disease,  each  of  which  is  attended  by  definite  altera- 
tions of  the  blood.  The  first  and  most  usual  type  is  that  in 
which  the  anaemia  is  the  result  of  internal  haemorrhage,  which, 
owing  to  the  absence  of  vomiting,  has  remained  unrecognised. 
In  the  second  class  are  included  those  cases  where  the  blood  so 
closely  resembles  that  of  pernicious  anaemia  that  from  a  clinical 
standpoint  the  two  complaints  may  be  said  to  coexist.  The 
third  group  comprises  those  rare  instances  in  which  enlarge- 
ment of  the  spleen  and  the  presence  of  an  excess  of  leucocytes 
in  the  blood  simulate  leucocythaemia. 

(a)  Anaemia  due  to  Concealed  Haemorrhage. — This  is  by  far  the 
most  common  variety,  and  is  often  associated  with  a  localised 
malignant  ulcer  of  the  posterior  surface  of  the  stomach.  After  a 
comparatively  short  period  of  ill-health  the  patient  loses  colour 
in  the  face  and  lips  and  complains  of  shortness  of  breath,  thirst, 
and  great  debility.     Not  infrequently  these  symptoms  develop 


CLINICAL  VAEIETIES  211 

suddenly  after  a  sharp  attack\>f  abdominal  pain  or  diarrhoea, 
which  is  attributed  to  indulgence  in  fruit  or  some  indigestible 
article  of  diet.  Contrary,  however,  to  expectation,  the  sym- 
ptoms increase  rather  than  diminish,  the  anaemia  gradually 
becomes  more  pronounced,  and  there  is  faintness,  giddiness, 
or  palpitation  upon  the  least  exertion.  The  appetite  is  greatly 
diminished,  there  is  a  steady  loss  of  flesh,  and  in  the  majority 
of  cases  discomfort  and  flatulence  are  experienced  after  every 
meal.  The  subsequent  progress  of  the  disease  is  variable.  In 
some  instances  the  anaernia  steadily  increases  and  is  attended 
by  the  usual  symptoms  of  cardiac  failure  ;  or  sudden  exacerba- 
tions of  weakness  and  debility  occur  at  irregular  intervals,  and 
are  accompanied  by  excessive  pallor.  In  other  cases  severe 
pain  after  food  is  experienced,  and  is  followed  by  vomiting, 
anorexia,  and  eventually  by  hsematemesis.  During  the  first  few 
months  physical  examination  throws  little  light  upon  the  nature 
of  the  complaint.  "With  the  exception  of  a  somewhat  feeble 
impulse,  and  perhaps  of  a  murmur  over  the  pulmonary  area,  the 
heart  appears  to  be  healthy,  and  the  lungs  are  quite  normal. 
The  pulse  is  small  and  of  low  tension,  the  temperature  is  slightly 
elevated  at  night,  and  there  may  be  oedema  of  the  ankles.  No 
enlargement  or  tumour  of  the  stomach  can  be  detected,  and  the 
urine  is  quite  healthy.  After  a  time,  .however,  increasing  pain 
is  experienced  in  the  epigastrium  or  right  hypochondrium,  the 
temperature  remains  permanently  subnormal,  emaciation  pro- 
ceeds rapidly,  the  liver  becomes  enlarged,  and  ascites  or  jaundice 
develops.  In  other  instances  the  pain  after  food  and  vomiting 
become  excessive,  the  stomach  undergoes  dilatation,  and  a 
growing  and  painful  tumour  is  detected  in  connection  with  the 
viscus.  An  early  diagnosis  can  be  made  only  by  examination 
of  the  contents  of  the  stomach.  For  this  purpose  a  soft  tube 
is  passed  into  the  organ  during  the  period  of  digestion,  when 
the  evacuated  material  is  found  to  contain  altered  blood,  some- 
times in  considerable  quantity.  Free  hydrochloric  acid  is 
invariably  absent,  but  lactic  acid  may  not  exist  until  a  late 
stage  of  the  disease.  Examination  of  the  blood  shows  a  great 
reduction  in  the  number  of  red  corpuscles  and  of  haemoglobin, 
but  an  absence  of  poikilocytosis.  The  average  duration  of  life 
is  about  eight  months. 

Case  XIII.  A  man  aged  forty -nine  was  admitted  into  the  London 
Temperance  Hospital  for  anaemia.     He  stated  that  he  had  enjoyed 


212  CANCEE  OF  THE   STOMACH 

excellent  health  until  about  five  months  previously,  when  he  noticed 
that  he  had  grown  very  pale  and  was  short  of  breath  on  exertion. 
The  appetite  was  poor  and  he  was  very  thirsty  at  night.  These 
symptoms  continued  to  increase,  and  he  also  steadily  lost  flesh  and 
became  very  weak.  After  meals  containing  solid  food  he  often 
felt  a  sense  of  oppression  at  the  chest,  but  there  had  been  no  actual 
pain  or  vomiting.  On  examination  he  was  found  to  be  profoundly 
anaemic  and  very  wasted.  The  pulse  was  small  and  feeble,  the 
temperature  elevated  about  a  degree  and  a  half  at  night,  and  the 
tongue  was  pale,  flabby,  and  indented  by  the  teeth.  The  stomach 
was  slightly  increased  in  size,  and  pressure  over  the  epigastrium 
produced  discomfort  and  nausea,  but  no  resistance  or  tumour 
could  be  detected.  The  bowels  were  confined.  There  was  slight 
oedema  of  the  ankles,  but  the  urine  contained  neither  sugar  nor 
albumin.  The  red  corpuscles  were  reduced  to  54  per  cent,  of  the 
normal  and  the  haemoglobin  to  44  per  cent.  There  was  no  excess  of 
leucocytes  or  poikilocytosis.  After  a  test  breakfast  about  ten  ounces 
of  thick  brownish-black  material  was  removed  from  the  stomach  by 
the  tube,  which  was  found  to  consist  of  undigested  food,  mucus,  and 
altered  blood,  but  contained  neither  free  hydrochloric  nor  lactic  acid. 
The  following  day  the  tube  was  again  passed  before  any  food  had 
been  given,  and  several  ounces  of  alkaline  blood-stained  fluid  were 
removed.  On  several  subsequent  occasions  altered  blood  was  dis- 
covered in  the  stomach  during  the  periods  of  digestion,  but  no 
melaena  was  ever  observed.  Despite  careful  treatment  the  patient 
grew  rapidly  weaker,  and  eventually  succumbed  to  exhaustion  about 
six  and  a  half  months  after  the  appearance  of  the  first  symptoms. 
Post-mortem  examination  showed  a  large  ulcerated  scirrhous  growth 
on  the  posterior  wall  of  the  stomach,  near  the  pylorus.  The  orifice 
was  not  involved,  nor  were  there  any  metastases  in  the  neighbouring 
organs. 

Case  XIV.  A  middle-aged  man  was  admitted  into  hospital  under 
our  care  on  account  of  debility  and  loss  of  flesh.  The  first  symptoms 
of  ill-health  had  consisted  of  breathlessness,  weakness  of  the  legs,  and 
flatulence  after  food,  with  great  distaste  for  meat.  The  bowels  were 
confined,  and  nausea  with  occasional  vomiting  had  been  experienced 
in  the  early  morning.  Examination  showed  the  patient  to  be  pro- 
foundly anaemic  and  emaciated.  The  lower  border  of  the  stomach 
reached  to  the  level  of  the  umbilicus,  and  pressure  over  the  centre  of 
the  epigastrium  gave  rise  to  pain.  There  was  no  tumour,  and  the 
other  viscera  of  the  body  were  healthy.  The  corpuscular  richness  of 
the  blood  was  54  per  cent,  of  the  normal  and  that  of  the  haemoglobin 
48  per  cent.  There  was  also  a  slight  excess  of  leucocytes.  After  a 
test  meal  the  contents  of  the  stomach  were  found  to  be  devoid  of  free 
hydrochloric  acid,  but  to  contain  an  excess  of  lactic  acid. 


CLINICAL  VAEIETIES  213 

For  nearly  a  fortnight  the  patient  showed,  signs  of  improvement 
and  gained  half  a  pound  in  weight,  but  at  the  end  of  that  time  he 
grew  suddenly  worse  and  the  anaemia  became  much  more  pronounced. 
Exploration  of  the  stomach  after  the  midday  meal  led  to  the  evacua- 
tion of  a  large  quantity  of  altered  blood.  From  this  haemorrhage 
he  gradually  rallied,  but  began  to  complain  of  pain  after  food,  which 
grew  more  severe  and  was  also  troublesome  at  night.  The  liver 
became  enlarged,  and  a  hard  tender  tumour  developed  under  the  right 
costal  margin.  Six  weeks  later  the  liver  extended  nearly  to  the  umbili- 
cus, and  presented  several  discrete  tumours  in  the  substance  of  the  right 
lobe.  Ascites  occurred  and  was  followed  by  jaundice,  and  the  patient 
fell  into  a  comatose  state,  which  terminated  fatally  in  three  days. 

Necropsy.  The  liver  was  extensively  infiltrated  with  soft  car- 
cinoma, and  several  nodules  presented  recent  haemorrhages.  Near  the 
lesser  curvature  of  the  stomach,  in  the  posterior  wall,  there  was 
an  ulcerated  growth  of  cylinder-celled  carcinoma  about  the  size  of  a 
two-shilling  piece. 

(b)  Profound  Ancemia  with  Blood  Changes  similar  to  those 
of  Pernicious  Ancemia. — Cases  of  this  description  are  much 
rarer  than  those  of  the  preceding  group.  The  onset  of  the 
complaint  is  insidious,  and  characterised  by  progressive  pallor 
of  the  skin  and  mucous  membranes,  which  subsequently 
changes  to  the  lemon  tint  so  often  observed  in  idiopathic 
anaemia.  At  the  same  time  the  patient  suffers  from  loss  of 
appetite  and  thirst,  and  becomes  markedly  emaciated  and  feeble. 
Gastric  symptoms  are  almost  always  present,  but  vary  from 
occasional  attacks  of  discomfort  and  flatulence  to  severe  pain 
and  vomiting  after  each  meal.  The  bowels  are  usually  confined, 
but  at  a  late  stage  of  the  disease  diarrhoea  is  apt  to  alternate 
with  constipation.  In  most  cases  the  temperature  is  elevated 
at  first,  but  subsequently  remains  subnormal.  Thrombosis  is 
apt  to  occur  in  the  veins  of  the  lower  extremities,  and  pneu- 
monia is  often  the  immediate  cause  of  death.  Examination  of 
the  stomach  seldom  affords  any  distinctive  evidence  of  disease, 
since  the  growth  usually  occupies  the  central  region  of  the  organ. 
At  a  late  stage,  however,  gastric  dilatation  may  be  observed,  or 
a  tumour  may  develop.  In  every  instance  the  gastric  contents 
are  devoid  of  free  hydrochloric  acid,  but  the  presence  of  lactic 
acid  and  of  the  Oppler-Boas  bacillus  is  variable.  The  blood  is 
very  pale  and  exhibits  a  great  diminution  of  red  corpuscles,  with 
poikilocytosis,  and  sometimes  nucleated  red  cells  and  megalo- 
blasts.     Occasionally  retinal  haemorrhages  develop,  or  bleeding 


214  CANCEE  OF  THE   STOMACH 

takes  place  from  various  mucous  membranes  or  into  one  of  the 
serous  cavities  (Bouveret).  Death  usually  occurs  within  nine 
months. 

Case  XV.  A  man  about  fifty  years  of  age  was  admitted  into 
hospital  for  '  pernicious  anaemia.'  He  stated  that  his  health  had  been 
failing  for  seven  months,  during  which  time  he  had  lost  nearly  two 
stones  in  weight  and  had  become  extremely  weak.  He  had  also  grown 
very  pale,  and  found  that  the  least  exertion  gave  rise  to  breathlessness 
and  palpitation.  The  appetite  was  very  bad,  and  after  meals  he  had 
suffered  from  distension  of  the  stomach,  nausea,  and  flatulence. 
There  had  never  been  any  vomiting  or  hgematemesis,  and  the  bowels 
were  constipated. 

Examination  showed  him  to  be  very  emaciated.  The  eyelids  were 
puffy,  the  lips  and  conjunctivae  pallid,  and  the  skin  a  pale  lemon 
colour.  There  was  marked  oedema  of  the  ankles.  No  signs  of 
pulmonary  disease  could  be  detected,  but  there  was  a  loud  systolic 
bruit  over  the  base  of  the  heart  on  the  left  side.  The  stomach 
extended  to  the  level  of  the  navel,  and  pressure  over  the  epigastrium 
gave  rise  to  pain,  but  no  tumour  or  resistance  could  be  felt.  The 
other  organs  were  apparently  healthy.  The  blood  showed  red  cor- 
puscles 26  per  cent.,  haemoglobin  19  per  cent.,  well-marked  poikilo- 
cytosis  and  a  few  typical  megaloblasts.  The  gastric  contents  were 
devoid  both  of  free  hydrochloric  and  lactic  acid.  During  his  resi- 
dence in  the  hospital  the  gastric  symptoms  increased,  and  on  several 
occasions  he  vomited  after  meals.  Emaciation  made  rapid  progress, 
and  the  anorexia  became  absolute,  so  that  the  greatest  difficulty 
was  experienced  in  the  administration  of  food.  The  temperature  was 
slightly  elevated  at  night  but  subnormal  in  the  morning,  and  from 
time  to  time  the  constipation  was  replaced  by  diarrhoea.  A  few 
small  haemorrhages  also  developed  in  the  retina  of  the  right  eye. 
Death  occurred  suddenly  from  syncope  at  the  end  of  three  weeks. 
At  the  necropsy  the  greater  part  of  the  posterior  surface  of  the 
stomach  was  found  to  be  affected  with  an  exuberant  soft  growth  of 
spheroidal-celled  carcinoma,  which  had  given  rise  to  a  small  encysted 
collection  of  pus  behind  the  organ.  The  glands  along  the  lesser 
curvature  were  enlarged,  but  there  were  no  metastases  in  the  liver 
or  other  organs. 

(c)  Ancemia  with  an  Excess  of  White  Corpuscles  in  the  Blood. 
Alexandre  and  other  writers  have  described  cases  of  carcinoma 
of  the  stomach  in  which  the  symptoms  of  severe  anaemia  were 
associated  with  a  great  excess  of  white  corpuscles  (leuchaemia) . 
Three  cases  of  this  description  are  included  in  our  hospital 
series,  and  in  each  instance  the  spleen  was  much  enlarged. 


CLINICAL  VARIETIES  215 

The  first  symptoms  of  ill-health  consisted  of  breathlessness  on 
exertion,  debility,  palpitation,  and  discomfort  after  meals,  and 
the  patients  subsequently  complained  of  loss  of  flesh,  want  of 
appetite,  and  at  a  later  period  of  pain  after  food  and  repeated 
vomiting.  In  two  cases  the  stomach  underwent  considerable 
dilatation,  and  a  tumour  was  detected  in  the  epigastrium,  but  in 
the  other  no  special  signs  of  the  gastric  complaint  existed 
during  life.  In  each  the  spleen  was  easily  palpable,  but  it 
never  projected  more  than  three  inches  below  the  costal  margin, 
and  was  not  accompanied  by  enlargement  of  the  lymphatic 
glands.  Free  hydrochloric  acid  was  absent  in  the  only  case 
where  the  result  of  an  examination  of  the  gastric  contents  was 
recorded,  and  in  every  instance,  in  addition  to  a  diminution  of 
the  red  corpuscles,  there  was  a  marked  increase  in  the  number 
of  white  cells,  the  ratio  of  red  to  white  varying  from  70  to 
1  to  12  to  1  Thrombosis  of  the  femoral,  iliac,  or  popliteal 
veins  invariably  occurred  before  death,  and  two  cases  succumbed 
to  pneumonia.  The  average  duration  of  life  was  about  eleven 
months.  It  is  interesting  to  note  that  in  only  one  out  of  the 
three  cases  was  a  correct  diagnosis  made  during  life,  the  other 
two  being  regarded  as  examples  of  leucocythsemia. 

Case  XVI.  A  woman,  thirty-three  years  of  age,  had  complained 
of  weakness,  dyspnoea,  and  palpitation  for  nearly  six  months.  When 
admitted  into  hospital  she  was  markedly  anaemic  and  thin,  and 
exhibited  a  great  distaste  to  food.  The  spleen  was  considerably 
enlarged,  and  the  blood  showed  a  vast  excess  of  white  corpuscles, 
the  proportion  of  red  to  white  being  26  to  1.  The  stomach 
was  slightly  dilated,  and  in  the  epigastrium  an  ill-defined  tender 
tumour  could  be  felt.  About  a  week  later  she  was  attacked  by 
thrombosis  of  the  left  femoral  vein,  and  subsequently  by  pneumonia, 
which  terminated  fatally.  After  death  cancer  of  the  pylorus  and 
lesser  curvature  was  discovered,  with  secondary  disease  of  the  great 
omentum.  The  spleen  was  large,  firm,  and  pale,  but  did  not  contain 
any  secondary  growths. 

Case  XVII.  A  man,  aged  fifty-six,  was  admitted  into  hospital  for 
anaemia.  The  history  was  very  indefinite,  but  he  had  apparently 
been  out  of  health  for  four  months,  and  had  become  too  weak  to 
pursue  his  work  as  a  general  labourer.  There  was  no  complaint  of  pain 
or  sickness,  but  he  had  become  greatly  emaciated  and  was  very  short 
of  breath.  On  examination  he  presented  profound  anaemia,  with 
oedema  of  the  ankles  and  a  pleuritic  effusion  on  the  left  side.  The  spleen 
projected  three  inches  below  the  costal  margin,  but  the  organ  was  not 


216  CANCEE  OF  THE   STOMACH 

tender  and  its  surface  was  quite  smooth.  The  patient  had  never 
suffered  from  malaria.  Just  to  the  right  of  the  navel  was  a  round, 
movable,  tender  tumour  about  the  size  of  a  Tangerine  orange, 
apparently  connected  with  the  stomach,  which  was  somewhat  dilated. 
The  gastric  contents  were  free  from  hydrochloric  acid,  and  the  blood 
contained  a  great  excess  of  white  corpuscles.  On  several  occasions  the 
patient  vomited  after  dinner,  but  there  was  no  hsematemesis.  Pain  and 
swelling  of  the  left  leg  developed,  the  temperature  rose  to  100°  E., 
and  the  general  debility  increased.  Death  occurred  from  exhaustion 
within  four  weeks.  A  necropsy  showed  carcinoma  of  the  pylorus 
with  slight  contraction  of  the  orifice,  a  few  secondary  growths  in  the 
pancreas,  and  a  large  but  apparently  healthy  spleen. 

(9)  Carcinoma  originating1  in  Simple  Ulcer  (Ulcus  Carci- 
nomatosum). — The  frequency  with  which  cancer  of  the 
stomach  is  preceded  by  a  simple  ulcer  is  a  matter  that  has 
given  rise  to  much  discussion.  According  to  Lebert,  about  9 
per  cent,  of  all  gastric  carcinomata  originate  in  the  benign 
complaint ;  Sonicksen's  estimate  is  14  per  cent.,  Bosenheim's 
6  per  cent.,  Plange  and  Berthold's  3  per  cent.,  Steiner  and 
Wollmann's  4  per  cent.,  while  Zenker  seems  to  regard  simple 
ulceration  as  a  necessary  antecedent  to  the  malignant  affection. 
Personally,  we  are  inclined  to  agree  with  Haberlin  that  only 
about  3  per  cent,  of  all  cases  of  gastric  cancer  present  a 
clinical  history  or  post-mortem  evidence  of  previous  ulceration. 

Since  1845  about  thirty-two  examples  of  the  disease  have 
been  published,  and  although  a  critical  examination  of  many  of 
the  cases  tends  to  throw  considerable  doubt  upon  their  authen- 
ticity, several  facts  of  importance  may  be  gleaned  from  them. 
As  might  have  been  expected  from  the  etiology  of  the  simple 
complaint,  women  are  more  often  affected  than  men  (20  :  12), 
and  the  pyloric  end  of  the  stomach  is  almost  invariably  the 
seat  of  the  growth.  As  a  general  rule,  the  symptoms  of  the 
malignant  disease  are  gradually  engrafted  upon  those  of  the 
chronic  ulcer,  but  in  about  one  fifth  of  the  cases  an  interval 
varying  from  a  few  months  to  several  years  existed  between 
the  apparent  healing  of  the  ulcer  and  the  development  of  the 
neoplasm.  A  careful  perusal  of  the  recorded  cases  seems  to 
indicate  that  the  carcinoma  ex  ulcere  may  be  divided  into  three 
classes. 

In  the  first  group  the  indications  of  malignant  mischief 
steadily  develop,  and    finally   predominate    over   those  of  the 


CLINICAL  VAEIETIES  217 

ulcer;  in  the  second  they  remain  latent  throughout,  while 
the  pain,  vomiting,  and  hsematemesis  of  the  primary  disease 
continue  until  the  end  ;  while  in  the  third  all  gastric  symptoms 
remain  in  abeyance,  and  the  physical  signs  indicate  cancer  of 
the  liver,  peritoneum,  or  pancreas. 

(a)  Cases  in  which  the  Symptoms  of  Carcinoma  are 
engrafted  upon  those  of  Simple  Ulcer  constitute  about  80  per 
cent,  of  the  entire  number.  When  the  indications  of  an 
ulcer  have  persisted  up  to  the  time  of  its  malignant  invasion, 
they  gradually  become  aggravated,  pain  and  vomiting  are 
excited  by  liquid  as  well  as  by  solid  food,  and  a  constant 
sensation  of  nausea  may  be  present.  On  the  other  hand,  the 
appetite  may  continue  good  for  several  months,  or  even  persist 
until  the  end.  Attacks  of  pyrosis  are  apt  to  occur  at  night, 
loss  of  flesh  takes  place  rapidly,  and  debility  and  cachexia  are 
always  prominent  features  of  the  complaint.  Severe  hgernat- 
emesis  is  rare,  but  small  quantities  of  altered  blood  are  some- 
times observed  in  the  vomit  or  in  the  material  extracted  from 
the  stomach  by  a  tube.  After  a  period  varying  from  three  to 
six  months  the  appetite  declines,  the  debility  and  emaciation 
make  rapid  progress,  and  the  patient  grows  very  depressed,  and 
often  expresses  a  conviction  that  his  disease  will  prove  fatal. 
The  last  phase  is  marked  by  complete  anorexia,  extreme 
asthenia  and  cachexia,  and  intolerance  of  any  kind  of  food. 
The  physical  signs  of  malignant  disease  are  very  indefinite. 
The  epigastric  tenderness  which  had  attended  the  simple  ulcer 
is  sometimes  intensified,  but  in  the  absence  of  secondary 
growths  in  the  omentum  a  tumour  can  rarely  be  detected. 
Owing  to  the  fact  that  the  neoplasm  usually  remains  localised, 
the  signs  of  pyloric  stenosis  are  wanting,  and  it  is  rare  for  the 
liver  to  present  palpable  growths  or  for  the  glands  above  the 
left  clavicle  to  become  enlarged.  The  results  of  an  exploration 
of  the  stomach  are  also  equivocal,  since  the  pre-existing 
hyper-secretion  usually  persists  for  several  months  after  the 
onset  of  the  carcinoma,  and  may  continue  until  the  end.  As  a 
rule,  however,  the  secretion  of  the  mineral  acid  gradually  fails, 
and  after  a  few  months  lactic  acid,  with  or  without  the  Oppler- 
Boas  bacillus,  may  be  detected  in  the  gastric  contents. 

When  carcinoma  attacks  an  ulcer  which  has  undergone  cica- 
trisation, or  which  has  remained  latent  for  some  time,  it  is  much 
less  difficult  to  recognise.     The  patient  usually  imagines  that 


218  CANCEE  OF  THE   STOMACH 

her  old  malady  has  recurred,  and  seeks  medical  advice  on 
account  of  renewed  pain  or  discomfort  after  food,  and  vomiting- 
It  is  observed,  however,  that,  unlike  the  simple  complaint,  there 
has  been  a  steady  loss  of  flesh  and  strength  from  the  onset  of 
the  dyspeptic  symptoms ;  anaemia  soon  becomes  a  prominent 
feature,  and  the  blood  exhibits  a  steady  diminution  of  red 
corpuscles  and  haemoglobin.  The  appetite  is  also  affected  at 
an  early  period,  and  complete  anorexia  is  sometimes  established 
after  a  few  months.  The  gastric  symptoms  increase  in 
severity,  and  if  the  growth  involves  the  tissues  surrounding  the 
scar,  as  it  usually  does,  the  pylorus  is  apt  to  become  obstructed 
and  to  give  rise  to  periodic  vomiting.  This  variety  is  more 
often  accompanied  by  the  presence  of  a  tumour  than  the  pre- 
ceding, and  in  most  instances  the  liver  or  peritoneum  shows 
signs  of  invasion  before  death.  The  gastric  contents  vary 
according  to  the  situation  of  the  former  ulcer ;  but  unless  it 
was  located  in  the  immediate  vicinity  of  the  pyloric  orifice, 
hyper-secretion  is  usually  absent,  and  free  hydrochloric  acid  is 
replaced  by  lactic  acid  at  an  early  period  of  the  complaint. 

Case  XVIII.  A  man,  forty-eight  years  of  age,  was  admitted  into 
hospital  under  our  care  in  1887  for  a  chronic  ulcer  of  the  stomach. 
For  more  than  a  year  he  had  complained  of  pain  and  sickness  after 
meals,  and  on  two  occasions  had  vomited  a  large  quantity  of  blood. 
Under  treatment  these  symptoms  eventually  subsided,  and  he 
apparently  became  cured.  In  1890  he  again  sought  admission  into 
hospital  for  severe  indigestion.  According  to  his  statement  he  had 
been  perfectly  free  from  pain  for  more  than  a  year,  when,  after  a  few 
weeks  of  ill-health,  he  began  to  experience  a  sense  of  weight  and 
oppression  at  the  chest  after  meals,  attended  by  flatulence,  nausea, 
and  want  of  appetite.  During  the  last  two  months  he  had  lost 
much  flesh  and  felt  very  weak.  There  had  been  no  vomiting  or 
haematemesis.  On  examination  he  was  found  to  be  very  thin  and 
markedly  anaemic.  The  stomach  was  somewhat  dilated,  and  pressure 
over  the  region  of  the  pylorus  gave  rise  to  pain,  but  no  tumour  could 
be  discovered.  The  temperature  was  subnormal,  the  urine  healthy, 
and  the  blood  showed  a  great  reduction  in  the  number  of  red 
corpuscles  and  of  haemoglobin,  with  slight  leucocytosis.  After  a  test 
meal  the  contents  of  the  stomach  gave  the  reaction  for  free  hydro- 
chloric acid,  but  were  free  from  lactic  acid.  For  two  or  three  weeks 
a  milk  diet  was  attended  by  improvement,  but  subsequently  the 
discomfort  after  meals  increased  and  vomiting  occurred  each  night. 
The   patient    continued    to    lose   flesh   and    strength,    and   on  two 


CLINICAL  VARIETIES  219 

occasions  exploration  of  the  stomach  with  a  tube  revealed  the 
existence  of  altered  blood  in  the  organ.  Free  hydrochloric  acid 
disappeared  about  the  fifth  month  of  the  disease,  but  no  lactic  acid 
was  ever  detected.  Shortly  afterwards  he  was  attacked  by  pneumonia, 
to  which  he  succumbed. 

Necropsy.  On  the  posterior  wall  of  the  stomach,  about  two  inches 
from  the  pylorus,  was  a  chronic  ulcer  the  size  of  a  five-shilling  piece. 
Growing  from  its  lower  margin  and  base  was  a  large  firm  growth  of 
greyish-brown  colour,  which  on  microscopical  examination  proved  to 
be  a  spheroidal-celled  carcinoma.  The  lymphatic  glands  along  the 
lesser  curvature  and  behind  the  stomach  were  enlarged,  but  there 
were  no  metastases  in  the  liver  or  other  organs. 

Case  XIX.  A  woman,  aged  thirty-five  years,  was  admitted  into  the 
Westminster  Hospital  on  April  12,  1900,  suffering  from  what  was 
supposed  to  be  a  gastric  ulcer.  She  stated  that  in  1894,  about  a 
month  after  the  birth  of  her  first  child,  she  had  pain  in  the  chest  and 
back,  coming  on  soon  after  food  and  relieved  by  vomiting,  but 
unattended  by  haematemesis.  This  lasted  for  three  and  a  half  years, 
when  the  symptoms  subsided,  and  for  six  months  she  suffered  from  no 
discomfort  or  inconvenience.  A  month  before  the  second  child  was 
born  she  had  another  attack,  which  lasted  nine  months,  during  which 
time  she  frequently  brought  up  blood,  but  never  in  large  quantities. 
About  sixteen  months  ago  she  again  became  pregnant,  and  since 
then  had  suffered  constantly  from  gastric  symptoms.  The  pain  after 
meals  had  become  more  pronounced  and  the  vomiting  more  frequent. 
She  stated  that,  with  intermissions,  her  illness  had  lasted  for  six 
years,  and  during  the  last  two  years  she  had  lost  flesh  considerably. 

On  admission  the  patient  was  found  to  be  very  thin,  but  she 
presented  no  cachectic  appearance ;  her  weight  was  five  stones  eight 
pounds.  She  complained  of  a. feeling  of  oppression  in  the  epigastric 
region,  culminating  in  acute  pain  after  food  and  relieved  by  vomiting. 
The  vomited  matter  consisted  of  undigested  food  with  a  quantity  of 
yellow  frothy  fluid  having  an  acid  reaction.  There  was  very  little 
abdominal  tenderness,  the  stomach  was  only  slightly  dilated,  and 
there  was  some  thickening  about  the  pylorus.  The  temperature  was 
normal,  and  the  urine  had  a  specific  gravity  of  1020  and  contained  no 
albumin. 

The  patient  was  kept  in  bed  and  was  placed  on  three  pints  of  pep- 
tonised  milk — five  ounces  every  two  hours — with  plasmon  custard ;  but 
the  vomiting  was  so  persistent  that  nutrient  enemata  with  suppositories 
of  beef  peptones  were  substituted.  These  suppositories  contained 
50  per  cent,  of  peptone  of  beef,  and  each  weighed  72  grains.  The 
bowels  were  relieved  from  time  to  time  by  a  simple  enema.  On  this 
treatment  she  progressed  favourably  until  May  14,  when  there  was  a 
sudden  rise  of  temperature.     At  7  a.m.  it  was  103'4°  F.,  and  at  3  p.m. 


220  CANCEE  OF  THE   STOMACH 

it  was  104-6°,  the  pulse  being  136.  There  was  no  sore  throat,  or 
pneumonia,  or  endocarditis,  and  apparently  nothing  to  account  for  it. 
She  was  put  on  small  and  frequently  repeated  doses  of  tincture  of 
aconite,  and  on  the  following  day  the  temperature  fell  to  100°  E., 
although  henceforth  it  was  never  quite  normal  and  ranged  from 
100°  to  101°  F.  On  the  16th  she  started  an  attack  of  diarrhoea,  which 
proved  extremely  obstinate  and  continued  until  her  death.  There 
were  often  from  ten  to  twelve  evacuations  in  the  twenty-four  hours. 
The  motions  were  loose,  but  not  watery ;  they  were  small  and 
greenish-brown  in  colour,  not  slimy,  but  very  offensive.  Various 
modes  of  treatment  were  tried,  without  avail,  including  saturated 
solution  of  camphor  in  alcohol  (three  drops  every  five  minutes) 
drachm  doses  of  carbonate  of  bismuth  every  four  hours,  enemata  of 
opium  (fifteen  drops  of  the  tincture  in  two  ounces  of  mucilage  of  starch), 
and  from  time  to  time  pill  of  lead  and  opium.  That  these  remedies 
were  ineffectual  is  shown  by  the  fact  that  she  had  103  motions  in 
twenty  days,  exclusive  of  those  which  were  too  small  to  note.  Once 
or  twice  the  stools  were  dark  in  colour  and  contained  what  was 
apparently  broken-up  clot.  The  patient  gradually  lost  ground,  and 
early  in  May  a  small  nodular  mass  was  felt  to  the  right  of  the  middle 
line,  midway  between  the  umbilicus  and  the  ensiform  cartilage.  The 
stomach  was  dilated,  but  not  markedly  so.  On  May  26  it  was  obvious 
that  she  was  critically  ill.  She  was  losing  flesh  rapidly  and  was  too 
weak  to  get  out  of  bed.  There  was  considerable  anaemia,  and  the  face 
looked  almost  as  if  it  were  jaundiced,  although  the  conjunctivae  were 
white.  She  was  in  no  pain  but  took  very  little  nourishment.  The  tongue 
was  moist  and  tremulous,  and  there  were  streaks  of  fur  in  the  centre. 
The  diarrhoea  continued,  and  there  was  prolapse  of  the  rectum.  There 
was  no  albumin  or  sugar  in  the  urine.  The  stomach  was  more 
dilated,  but  the  liver  was  not  enlarged. 

Necropsy.  At  the  necropsy  the  stomach  was  found  to  be  adherent 
about  the  pylorus  to  the  liver.  It  was  dilated,  and  at  the  pylorus 
there  was  an  ulcer  consisting  of  two  distinct  parts.  One,  which  was 
directed  towards  the  stomach,  was  cicatrised,  and  this  was  adherent 
to  the  liver  ;  and  the  other,  directed  towards  the  pylorus,  was  fungoid 
in  appearance.  The  two  ulcers  together  were  of  about  the  size  of  a 
five-shilling  piece.  There  were  enlarged  glands  in  the  portal  fissure 
and  in  the  neighbourhood  of  the  growth.  There  were  no  secondary 
deposits  in  the  liver,  which  was  fatty.  The  intestines  showed  melanic 
contents  in  places,  and  the  villi  were  atrophied.  The  spleen,  adrenals, 
pancreas,  kidneys,  bladder,  uterus,  and  ovaries  were  normal.  Micro- 
scopical examination  of  the  growth  showed  that  the  condition  was 
one  of  spheroidal  carcinoma.  The  muscular  tissue  about  the  pylorus 
was  being  invaded  by  a  growth  poor  in  cells  and  suggesting  scirrhus. 
Recorded  by  Dr.  Murrcll. 


CLINICAL  VAEIETIES  221 

(b)  In  about  15  per  cent,  of  the  cases  the  symptoms  of 
gastric  ulcer  continue  prominent  throughout  the  ichole  course 
of  the  co?nplaint.  Pain  is  experienced  after  every  meal, 
whether  it  be  composed  of  liquids  or  solids,  and  in  many 
instances  there  is  a  marked  intolerance  of  milk.  Vomiting 
occurs  frequently,  and  is  often  particularly  troublesome  at 
night,  while  from  time  to  time  attacks  of  excessive  retching 
supervene,  which  persist  for  several  days  and  preclude  the 
administration  of  food  by  the  mouth.  Pyrosis  is  almost 
always  a  source  of  complaint,  and  extreme  thirst  may  be 
present.  As  a  rule,  the  appetite  gradually  diminishes  or  is 
replaced  by  an  intense  craving  for  food,  which  disappears  after 
a  few  mouthfuls  have  been  swallowed.  Loss  of  flesh  is 
invariably  a  marked  feature  of  the  case,  and  the  patient 
becomes  exhausted  after  the  least  exertion.  Profuse  ha?mat- 
emesis  is  also  apt  to  occur,  and  may  prove  fatal,  while  occasion- 
ally life  is  suddenly  cut  short  by  perforation  of  the  stomach. 
Examination  of  the  abdomen  rarely  affords  any  evidence  of 
carcinoma,  since  a  tumour  and  secondary  growths  are  seldom 
encountered,  while  any  dilatation  of  the  stomach  which  may 
exist  is  usually  ascribed  to  the  ulcer.  The  gastric  contents 
usually  exhibit  an  excess  of  free  hydrochloric  acid  for  several 
months,  and  not  infrequently  the  signs  of  hyper- secretion 
continue  until  the  end.  Cases  of  this  description  are  extremely 
difficult  to  diagnose,  and  it  is  only  by  noting  the  dispropor- 
tionate loss  of  flesh  and  strength,  and  perhaps  a  steady  diminu- 
tion in  the  secretion  of  hydrochloric  acid,  that  a  cancerous 
invasion  of  the  ulcer  can  even  be  surmised. 

(c)  Complete  latency  of  the  gastric  sy?np>toms  with  a  pre- 
cocious development  of  secondary  growths  in  the  liver  or 
peritoneum  occurs  in  only  about  5  per  cent,  of  the  cases.  In 
such  the  ulcer  of  the  stomach  appears  to  undergo  cicatrisation, 
but  leaves  behind  it  a  tendency  to  flatulence  and  distension 
after  meals,  with  an  enfeebled  appetite  and  great  weakness. 
After  this  condition  of  ill-health  has  continued  for  some 
months  attention  is  again  attracted  to  the  abdomen,  either  on 
account  of  pain  in  the  chest  or  back,  accompanied  by  signs  of 
enlargement  of  the  liver,  or  by  the  development  of  ascites. 
As  soon  as  these  signs  show  themselves  emaciation  progresses 
rapidly,  pain  or  vomiting  is  experienced  after  meals,  and  the 
disease  runs  its  usual  course. 


222  CANCER  OF  THE   STOMACH 

(10)  Carcinoma  of  the  Stomach  in  Early  Life  (Acute 
Carcinoma). — The  rare  occurrence  of  gastric  cancer  before 
the  age  of  thirty  has  already  been  noticed  (p.  88).  With- 
out much  trouble  we  have  been  able  to  collect  twenty-two 
cases  in  which  the  complaint  developed  between  thirteen  and 
thirty  years  of  age,  and  to  them  we  have  added  three  of  our  own. 
Of  these  twTenty-five  examples,  twenty-one  were  males  and  four 
females.  In  most  instances  the  growth  was  described  as 
encephaloid  or  scirrhus,  and  from  those  where  the  microscopical 
features  of  the  disease  were  recorded  it  would  seem  that  the 
cylinder-celled  variety  is  comparatively  infrequent. 

In  sixteen  cases  the  first  symptoms  appeared  quite  suddenly, 
and  became  pronounced  within  two  or  three  weeks,  while  in  the 
rest  there  was  a  history  of  antecedent  ill-health  which  varied  in 
duration  from  ten  days  to  two  months.  Pain  in  the  region  of 
the  stomach  existed  in  all  but  three  cases,  and  was  usually  in- 
creased by  food,  while  vomiting  occurred  in  every  instance 
except  two,  and  was  often  a  prominent  feature.  Anorexia 
was  a  less  conspicuous  symptom,  and  in  fourteen  instances  did 
not  appear  until  a  late  period,  while  in  six  a  desire  for  food  con- 
tinued until  a  few  days  before  death.  Fever  existed  in  four  cases, 
and  in  two  continued  for  several  weeks.  In  every  instance 
there  was  rapid  emaciation  and  anaemia,  and  in  five  ascites 
developed  at  an  early  stage,  owing  to  implication  of  the  liver 
or  peritoneum.  An  abdominal  tumour  or  enlargement  of  the 
liver  was  detected  in  nineteen  out  of  the  twenty-five  cases.  It  is 
important  to  nofce  that  carcinoma  of  the  stomach  in  early  life 
usually  runs  an  acute  course,  the  average  duration  of  the  disease 
in  our  cases  being  three  months,  while  in  more  than  one  half  it 
did  not  exceed  nine  weeks.  The  conclusions  arrived  at  by 
Mathieu  from  an  analysis  of  twenty-seven  cases  were  of  a 
similar  nature. 


223 


CHAPTEK   VIII 

COURSE,   DURATION,   AND  PROGNOSIS 

Course. — It  is  impossible  to  describe  in  any  but  general 
terms  the  course  pursued  by  carcinoma  of  the  stomach.  Not 
only  do  the  symptoms  vary  in  intensity  at  different  periods,  but 
those  which  were  at  first  most  conspicuous  often  disappear 
after  a  few  months,  while  others,  that  depend  upon  the  fortui- 
tous involvement  of  a  neighbouring  organ  or  upon  structural 
changes  in  the  growth  itself,  develop  with  startling  rapidity  and 
may  completely  change  the  clinical  aspect  of  the  case.  But,  in 
spite  of  every  alteration  in  the  symptomatology  or  physical 
signs,  one  fact  usually  stands  out  conspicuous  and  unmistak- 
able— improvement  is  rare  and  always  transitory,  and  the  health 
of  the  patient  steadily  declines. 

Among  the  special  symptoms  of  the  disease,  pain  usually 
exhibits  the  greatest  variation,  being  apt  to  subside  spon- 
taneously after  the  liver  has  become  involved,  to  be  relieved  by 
haemorrhage  or  a  change  of  diet,  and  to  alter  in  character  and 
time  of  onset  when  the  growth  undergoes  ulceration. 

Vomiting'  as  an  early  symptom  is  chiefly  encountered  in 
stricture  of  the  orifices.  In  disease  of  the  cardia  the  dysphagia 
and  regurgitation  of  food  steadily  increase  until  the  obstruction 
becomes  almost  absolute,  but  in  pyloric  cases  the  periodic 
attacks  of  emesis  are  often  interrupted  from  time  to  time  by 
symptoms  of  acute  gastritis,  which  persist  for  several  days  and 
may  give  rise  to  fatal  exhaustion. 

Spontaneous  cessation  of  vomiting  often  occurs  shortly  before 
death,  but  it  may  ensue  at  an  earlier  period,  owing  to  sloughing 
of  the  growth  which  caused  the  obstruction  or  to  the  establish- 
ment of  a  fistulous  communication  with  the  intestine. 

As  a  rule  the  anamia  develops  gradually,  and  repeated 
examinations  of  the  blood  show  a  slow  but  steady  diminution 
of  haemoglobin   and   red   corpuscles.      Occasionally,    however, 


224  CANCEE  OF  THE   STOMACH 

cachexia  develops  rapidly,  and  attains  within  a  few  days  the 
degree  which  it  usually  takes  months  to  produce,  or  a  sudden 
increase  of  pallor  occurs  at  irregular  intervals.  In  such  cases  it 
is  a  fair  assumption  that  ulceration  of  the  growth  has  heen 
accompanied  by  internal  haemorrhage,  which,  owing  to  the 
absence  of  a  systematic  examination  of  the  evacuations,  had 
escaped  attention. 

Emaciation  varies  in  degree  in  different  cases,  but  is  always 
progressive.  It  is  most  rapid  in  cases  of  stricture  of  the  cardiac 
or  pyloric  orifice,  and  in  those  where  anorexia  and  vomiting  are 
early  and  prominent  symptoms.  The  loss  of  flesh  is  compara- 
tively slow  when  a  non-ulcerated  growth  occupies  the  wall  or 
gradually  infiltrates  the  entire  stomach. 

Temporary  increase  of  weight  is  often  observed  in  cases  of 
pyloric  stenosis  which  are  subjected  to  lavage  and  careful  feed- 
ing, and  after  the  performance  of  an  exploratory  laparotomy  or 
gastroenterostomy.  Eenewed  hope  also  exercises  a  beneficial 
influence  upon  the  general  nutrition,  so  that  a  patient  who  is 
assured  of  recovery  by  a  new  medical  attendant  will  often  regain 
appetite  and  weight  for  several  weeks.  A  fictitious  increase  of 
weight  usually  accompanies  an  effusion  of  fluid  into  the  peri- 
toneal or  pleural  cavities,  general  oedema,  or  a  rapid  infiltration 
of  the  liver. 

Although  the  course  of  carcinoma  of  the  stomach  depends 
to  a  great  extent  upon  the  situation  of  the  disease  and  the 
various  complications  incidental  to  its  development,  there  can 
be  little  doubt  that  it  is  also  largely  influenced  by  the  rate  of 
growth  of  the  tumour  at  different  times.  In  every  case  there 
probably  exist  certain  periods  of  latency,  the  duration  of  which 
varies  according  to  the  structure  of  the  neoplasm,  its  location  in 
the  stomach,  and  the  vulnerability  of  the  tissues.  Thus,  there 
is  every  reason  to  believe  that  an  appreciable  interval  always 
exists  between  the  commencement  of  the  carcinoma  and  the 
appearance  of  the  first  symptoms  of  disordered  digestion,  which 
is  comparatively  short  when  a  medullary  or  cylinder-celled 
growth  affects  the  cardia  or  pylorus,  but  is  often  protracted  in  the 
case  of  a  localised  scirrhus  of  the  body  of  the  viscus.  Again,  it 
frequently  happens  that  after  the  disease  has  pursued  an  acute 
course  for  the  first  few  months  the  urgent  symptoms  abate,  the 
rate  of  emaciation  diminishes,  and  life  is  prolonged  for  many 
months  beyond  the  period  originally  anticipated.     In  such  it  is 


COUESE,   DUEATION,   AND  PEOGNOSIS  225 

usual  to  find  after  death  either  that  the  primary  growth  presents 
evidence  of  partial  repair,  or  that  it  is  largely  composed  of 
fibrous  elements,  which  indicate  a  retrograde  activity.  On  the 
other  hand,  cases  are  often  met  with  in  which,  after  a  period  of 
slow  development,  the  pain,  vomiting,  and  cachexia  undergo  a 
sudden  exacerbation,  the  liver  becomes  rapidly  affected  by 
metastases,  and  life  is  cut  short  in  a  few  weeks,  while  a  necropsy 
shows  extensive  sloughing  of  the  tumour  or  an  exuberant 
growth  at  the  edge  or  base  of  a  scirrhous  induration.  Whether 
these  variations  of  malignancy  depend  upon  local  or  constitu- 
tional conditions  it  is  impossible  to  say,  but  the  fact  remains 
that,  except  under  certain  circumstances,  the  course  pursued 
by  the  disease  is  essentially  irregular,  and  consequently  impos- 
sible to  predict. 

Duration. — The  duration  of  carcinoma  of  the  stomach  is 
very  difficult  to  determine.  It  has  been  shown  that  the  onset 
of  the  symptoms  rarely,  if  ever,  coincides  with  the  actual  com- 
mencement of  the  morbid  growth,  and  that  no  limit  can  be 
assigned  to  this  period  of  latency.  The  initial  phenomena  of  the 
disease  are  also  so  variable  that  the  degree  of  indisposition  neces- 
sary to  attract  attention  may  in  one  case  develop  within  a  few 
weeks,  while  in  another  it  is  delayed  for  several  months.  The 
personal  equation,  again,  is  always  a  factor  of  great  importance, 
some  individuals  being  affected  by  a  nervous  disposition  which 
causes  them  to  seek  advice  immediately  they  suffer  from  indi- 
gestion, while  others  continue  to  pursue  their  usual  avocations 
until  compelled  to  relinquish  them  by  excessive  debility.  The 
same  influence  becomes  evident  when  an  attempt  is  made  to 
elicit  the  history  of  the  illness,  the  one  class  being  wont  to  con- 
fuse antecedent  and  extraneous  symptoms  with  those  of  malig- 
nant disease,  while  the  other  tend  equally  to  obscure  the  issue 
by  denying  the  existence  of  ill-health  before  the  occurrence  of 
those  symptoms  of  which  they  immediately  complain.  These 
various  sources  of  error  are  naturally  predominant  in  statistics 
based  upon  hospital  practice,  where  patients  seldom  apply  for 
treatment  until  the  disease  has  already  made  considerable 
progress,1  and  who,  from  want  of  education,  can  rarely  give  an 
accurate  account  of  the  development  and  course  of  their  illness. 
Even  the  period  at  which  the  tumour  made  its  appearance  can- 

1  In  our  own  cases  the  average  duration  of  the  disease  at  the  time  of  the 
patients'  admission  into  hospital  was  five  months. 

Q 


226 


CANCEE  OF  THE   STOMACH 


not  be  relied  upon,  since  it  is  usually  discovered  by  accident 
after  it  has  already  attained  a  considerable  size.  Nor  is  the 
specialist  engaged  in  private  practice  able  from  his  own  obser- 
vations to  determine  the  usual  duration  of  the  malady  ;  for 
although  he  may  be  able  to  obtain  a  fairly  accurate  history  from 
his  patients,  the  subsequent  course  of  their  illness  is  always 
difficult,  and  often  impossible,  to  ascertain.  Finally,  the  general 
practitioner,  who  alone  possesses  the  opportunity  of  studying 
the  disease  from  beginning  to  end,  seldom  sees  a  sufficient 
number  of  cases  to  allow  him  to  deduce  any  definite  conclusions 
from  them.  It  is  therefore  obvious  that  all  the  statistics  which 
we  at  present  possess  can  only  afford  a  rough  idea  of  the  average 
duration  of  the  complaint. 

From  the  study  of  198  cases  Brinton  estimated  the  average 
duration  of  cancer  of  the  stomach  at  twelve  and  a  half  months  ; 
Lebert  considered  it  to  be  fifteen  months,  with  a  maximum  of 
four  years ;  while  Katzenellenbogen  placed  the  usual  duration 
at  eighteen  months.  In  our  own  series  83  per  cent,  died  within 
twelve  months,  11  per  cent,  between  twelve  and  eighteen 
months,  and  about  6  per  cent,  between  eighteen  months  and 
two  and  a  half  years.  In  the  following  table  our  results  are 
compared  with  those  of  Lebert  and  Osier  and  McCrae. 

Table  28. — The  Duration  of  Carcinoma  of  the  Stomach 


Time  of  death 

Percentages  of  cases 

Authors' 

Lebert 

Osier  and  McCrae 

One  to  three  months    ..... 
Three  to  six  months    ..... 
Six  to  nine  months      ..... 
Nine  to  twelve  months         .... 
Twelve  to  eighteen  months  .... 
Above  eighteen  months        .... 

18-4 
32-8 
18-4 
13-6 
11-2 
5-6 

4 
17 
19 
23 
20 
17 

276 

29-3 

}         25-9 

5-2 
12 

Total 

100 

100 

100 

It  will  be  seen  that  while  Lebert's  figures  indicate  a  com- 
paratively long  duration,  our  own  closely  agree  with  those  of 
Osier  and  McCrae  in  the  main  fact  that  only  about '17  per  cent. 
of  all  cases  survive  longer  than  a  year.  As  a  rule  carcinoma 
of  the  stomach  in  early  life  runs  a  much  shorter  course  than  in 
adults,  according  to  Mathieu  the  mean  duration  of  cases  less 
than  thirty  years  of  age  being  about  three  months.     Colloid 


COUESE,  DUEATION,  AND  EEOGNOSIS  227 

cancer  is  also  relatively  frequent   in   the  young,  and  usually 
displays  a  considerable  rapidity  of  development. 

Most  authorities  allude  to  cases  which  were  supposed  to 
have  existed  for  periods  varying  from  three  to  ten  years  (twenty 
years — Ballou),  and  it  is  usually  stated  that  Napoleon  the  First 
died  from  a  cancer  of  the  stomach  of  nine  years'  duration.  But 
before  these  statements  can  be  accepted  certain  sources  of  error 
require  to  be  eliminated.  It  has  already  been  remarked  that  a 
neoplasm  sometimes  attacks  a  simple  ulcer  or  its  scar,  the 
evidences  of  which  it  obliterates  during  the  course  of  its  growth. 
It  consequently  follows  that  many  patients  give  a  history  of  pain 
after  food,  vomiting,  hgeniateinesis,  and  loss  of  flesh  extending 
over  a  considerable  number  of  years  prior  to  their  death  from 
carcinoma  of  the  stomach.  In  other  instances  some  functional 
disorder  of  the  stomach  or  colon  precedes  the  development  of 
the  fatal  malady,  but  owing  to  the  similarity  of  the  symptoms 
of  the  two  complaints  the  entire  illness  is  attributed  to  the 
final  and  fatal  disease.  This  seems  to  be  the  explanation  of  the 
statement  concerning  Napoleon's  illness,  for  in  the  numerous 
histories  of  his  life  no  evidence  is  forthcoming  of  the  anorexia, 
vomiting,  progressive  loss  of  flesh,  and  failure  of  strength  which 
invariably  accompany  even  the  most  chronic  form  of  cancer  of 
the  stomach ;  while  the  occasional  references  to  '  mon  pylore  ' 
during  his  attacks  of  abdominal  pain  were  probably  the  out- 
come of  the  confusion  that  exists  in  a  non-medical  mind  between 
symptoms  due  to  disease  of  the  stomach  and  those  that  arise 
from  a  disorder  of  the  colon.  On  the  other  hand,  the  increasing 
tendency  to  corpulence  which  marked  the  last  few  years  of  his 
life,  the  rapid  course  pursued  by  the  disease  when  once  it  became 
manifest,  and  the  delirium  that  preceded  death  for  a  fortnight, 
all  point  to  the  presence  of  a  growth  of  great  malignancy,  and 
consequently  of  short  duration. 

Although  the  question  of  average  duration  is  endowed 
with  a  certain  amount  of  interest,  it  is  of  little  value  to  the 
clinician,  who  has  to  offer  an  opinion  as  to  the  probable  dura- 
tion of  life  in  each  individual  case  that  comes  under  his  notice. 
It  is  therefore  necessary  to  consider  the  relative  influence 
exerted  by  certain  special  conditions  upon  the  progress  of  the 
complaint.  Of  these  the  most  important,  in  our  opinion,  is  the 
situation  of  the  growth  in  the  stomach.  In  the  following  table 
we  have  analysed  125  cases  in  order  to  show  the  proportional 


228 


CANCER  OF  THE   STOMACH 


death-rate  at  different  periods  in  carcinoma  of  various  regions 
of  the  stomach. 

Table  29. — Showing  the  Duration  of  Life  in  Carcinoma  of  Different 
Eegions  of  the  Stomach 


Duration  iu  months        .          .          .          j 

1-3         3-6 
mouths   months 

6-9      1     9-12     f    12-18 
months  j  months    months 

18-24    1 
months 

Cardia  (with  oesophageal  obstruction) 
Cardia  (oesophagus  not  affected) 
Walls  and  curvatures 
Pylorus  (with  stricture)   . 
Pylorus  (without  stricture) 
General  infiltration 

30-7%   38-5% 
12-5%   50% 
13%      30% 
13-5%   27% 
14%      28-5% 
12-5%   25% 

23-1%     7-7%      — 
12-5%   25%    1     — 
26%     j  17-4% :    8-6% 
27%     I  15-4%  :  11-5% 
11-4%  ;  22-8%  j  14-3% 
12-5%      —      37-5% 

4% 
5-6% 
9% 
12-5% 

It  will  be  observed  at  once  that  carcinoma  of  the  cardia  is 
more  rapidly  fatal  than  disease  of  any  other  part  of  the  organ, 
and  more  especially  in  those  cases  where  the  oesophagus  is 
obstructed  by  the  growth.  Thus,  of  the  cases  in  which 
dysphagia  occurred  as  an  early  symptom,  92  per  cent,  died 
within  nine  months,  while  of  those  where  the  oesophagus  was 
not  involved  75  per  cent,  succumbed  in  the  same  period.  In 
no  instance  did  disease  of  the  cardiac  third  of  the  stomach 
persist  for  more  than  a  year.  This  comparatively  short  dura- 
tion appears  to  depend  partly  upon  the  abnormal  rapidity  of 
growth  exhibited  by  neoplasms  in  this  region,  and  partly  upon 
the  inordinate  frequency  with  which  the  disease  gives  rise  to 
dysphagia,  inflammation  of  the  left  pleura,  and  secondary 
growths  in  the  liver  and  peritoneum. 

Next  in  order  of  rapid  fatality  are  cases  in  which  the  walls 
and  curvatures  of  the  stomach  are  primarily  affected  by  the 
neoplasm.  Of  such,  69  per  cent,  died  within  nine  months  and 
86  per  cent,  within  twelve  months,  while  only  4  per  cent, 
survived  more  than  eighteen  months.  Here  again  the  disease 
usually  exhibited  an  abnormally  rapid  growth,  and  frequently 
involved  the  liver  and  peritoneum. 

The  duration  of  life  in  disease  of  the  pylorus  depends  to  a 
great  extent  upon  the  condition  of  the  orifice.  In  those  cases 
where  there  was  marked  stenosis  67  per  cent,  died  within  nine 
months  and  83  per  cent,  within  a  year ;  while  of  those  which 
presented  a  patent  orifice,  or  where  the  obstruction  was  of 
secondary  importance,  only  54  per  cent,  succumbed  within  nine 
months  and  more  than  23  per  cent,  survived  a  year. 


COUESE,   DUEATION,  AND  PEOGNOSIS  229 

Contrary,  perhaps,  to  what  might  have  been  expected,  cases 
of  general  infiltration  of  the  stomach  often  progress  compara- 
tively slowly,  only  50  per  cent,  dying  within  nine  months  and 
about  the  same  proportion  surviving  between  one  and  two 
years.  The  fact  that  in  many  instances  of  this  kind  the 
symptoms  remain  slight  and  ill-defined  for  a  considerable 
period  renders  it  probable  that  the  average  duration  of  general 
cancerous  infiltration  is  even  longer  than  that  indicated ;  and 
from  our  own  experience  we  should  say  that,  in  the  absence  of 
pyloric  and  cardiac  obstruction  and  of  secondary  growths  in 
the  peritoneum,  life  may  sometimes  be  prolonged  for  three  or 
even  four  years. 

Early  implication  of  the  liver  or  peritoneum  exerts  an 
important  influence  upon  the  duration  of  the  disease.  Thus, 
of  those  cases  in  our  series  which  died  within  three  months, 
secondary  growths  were  found  in  the  liver  in  60  per  cent.,  but 
in  only  53  per  cent,  of  those  who  died  between  the  third  and 
sixth  months,  and  in  43  per  cent,  of  those  which  survived  that 
period.  In  like  manner,  the  peritoneum  was  found  to  be  affected 
in  40  per  cent,  of  those  who  succumbed  within  three  months, 
in  24  per  cent,  of  those  who  died  between  the  third  and  the  sixth 
months,  and  only  in  18  per  cent,  of  the  cases  that  survived  for 
a  longer  period. 

Prognosis. — The  prognosis  of  cancer  of  the  stomach  is 
always  hopeless,  for  there  is  no  authentic  case  on  record  in  which 
the  disease  was  ultimately  cured.  It  is  true  that  at  one  time 
the  discovery  of  the  partial  repair  that  occasionally  occurs  in  a 
malignant  ulcer  gave  rise  to  the  idea  of  a  '  spontaneous  cure  of 
cancer  ;  '  but  the  hope  implied  has  never  been  realised,  owing  to 
the  invariable  development  of  secondary  growths. 

The  course  of  the  disease  is  always  so  uncertain  that  it  is 
extremely  difficult  to  foretell,  even  approximately,  the  date  of 
the  fatal  issue.  In  our  opinion,  the  disappearance  of  the 
sulphocyanide  of  potassium  from  the  saliva  is  one  of  the  most 
important  indications  of  approaching  dissolution,  for  we  have 
never  observed  life  to  be  prolonged  for  more  than  a  month 
after  the  saliva  had  become  permanently  free  from  the  salt. 
Effusions  into  the  peritoneum  and  pleurae  are  always  associated 
with  rapid  deterioration  of  strength,  and  are  rarely  compatible 
with  the  prolongation  of  life  for  more  than  three  months. 
Rapidly  increasing  anaemia,  the  constant  presence  of  altered 


230 


CANCEE  OF  THE   STOMACH 


blood  in  the  contents  of  the  stomach,  diarrhoea,  and  a  steady 
diminution  in  the  tension  of  the  pulse,  all  point  to  an  early 
termination  of  the  disease.  The  cause  of  death  in  our  various 
cases  is  shown  in  the  following  table. 

Table  30. — Showing  the  Apparent  Cause  of  Death  in  265  Cases 
of  Carcinoma  of  the  Stomach 


Cause  of  death 


Percentage 


General  exhaustion 

Perforation  (acute  peritonitis)         .... 

Perforation  (local  abscess) 

Haemorrhage  ........ 

Endocarditis  (acute  and  chronic)   .... 

Pneumonia     ........ 

Hydrothorax  ........ 

Cerebral     complications     (apoplexy,    thrombosis, 
metastases,  coma)       ...... 

Intestinal  obstruction 

Bright's  disease 

Total 


191 
6 
8 
2 
8 
16 


18 


265 


72 
2-3 
3 

0-75 
3 
6 
3 

7 

2-3 

0-75 

100 


23] 


CHAPTEE   IX 
DIAGNOSIS 

The  problem  of  diagnosis  is  a  threefold  one.  In  the  first  place, 
it  is  necessary  to  consider  the  clinical  aspect  of  the  disease  in 
its  entirety,  in  order  to  establish  the  existence  of  certain 
general  features,  which  may  serve  to  distinguish  it  from  other 
disorders  of  the  digestive  organs.  In  the  second,  the 
symptoms  and  signs  which  develop  at  an  early  period  must  be 
separated  from  those  which  mark  an  advanced  stage  of  the 
complaint,  so  that  a  clue  may  be  obtained  to  the  recognition  of 
a  cancerous  growth  before  it  has  progressed  too  far  to  admit  of 
complete  removal.  Thirdly,  those  abnormal  varieties  of  the 
complaint  which  have  been  previously  described  require  to  be 
differentiated  from  other  diseases  to  which  they  bear  a  general 
resemblance. 

General  Diagnosis 

In  every  other  gastric  disease  the  symptoms  that  ensue 
from  the  disturbance  of  digestion  are  not  only  the  first  to 
attract  attention,  but  continue  of  primary  importance  through- 
out the  whole  course  of  the  malady.  But  in  cases  of  carcinoma 
the  secondary  or  constitutional  phenomena  always  seem  out 
of  proportion  to  the  disease  in  the  stomach,  and  often  con- 
stitute for  some  time  the  sole  sources  of  complaint.  In  this 
category  loss  of  flesh,  diminution  of  energy  and  strength,  and 
progressive  aneemia  are  the  most  conspicuous,  and  increase  m 
severity  in  spite  of  all  efforts  at  treatment.  Another  fact 
which  seldom  fails  to  impress  itself  upon  the  minds  of  on- 
lookers is  the  strange  pessimism  exhibited  by  the  patient,  who 
will  continue  to  avow  that  he  is  growing  worse  even  when  his 
symptoms  show   signs  of  remission,  or   even  subside  for  the 


232  CANCEE  OF  THE   STOMACH 

time.  Equally  rebellious  are  the  strictly  local  phenomena. 
If  flatulence  is  the  chief  cause  of  complaint,  it  remains  unin- 
fluenced by  the  administration  of  those  medicinal  remedies 
which  usually  relieve  it,  while  the  pain  after  food  is  rarely 
removed  by  the  most  careful  attention  to  diet.  In  like  manner, 
the  substitution  of  liquids  for  the  solid  forms  of  nourishment 
often  seems  to  increase  rather  than  to  allay  the  tendency  to 
emesis,  and  no  temptation  by  favourite  dishes  can  overcome 
the  increasing  dislike  to  meat  and  other  kinds  of  food.  Sooner 
or  later,  to  these  various  causes  of  suspicion  there  is  added  a 
symptom  which  at  once  directs  attention  to  the  serious  nature 
of  the  gastric  lesion  :  during  an  attack  of  vomiting,  or  as  a 
result  of  the  employment  of  a  tube,  the  ejecta  are  found  to  con- 
tain altered  blood,  or  the  patient  suffers  from  a  veritable  attack 
of  haemateniesis.  Unlike,  however,  the  haemorrhage  from  a 
simple  ulcer,  the  loss  of  blood  does  not  relieve  the  previous 
symptoms,  while  the  anaemia  to  which  it  gives  rise  continues 
to  increase,  and  is  unaffected  by  the  administration  of  iron. 

Examination  of  the  stomach  rarely  fails  to  throw  some 
light  upon  the  nature  of  the  disease.  Even  at  a  comparatively 
early  period  the  hydrochloric  acid  of  the  gastric  secretion  is 
found  to  be  much  diminished,  and  within  a  short  time  it  can 
no  longer  be  detected  in  a  free  state ;  while  in  most  cases  the 
disappearance  of  the  free  mineral  acid  is  associated  with  the 
production  of  lactic  acid  and  the  presence  of  the  Oppler-Boas 
bacillus.  Dilatation  of  the  stomach  is  almost  invariably  present 
when  the  growth  affects  the  pylorus,  and  as  the  organ  increases 
in  size  the  attacks  of  emesis  exhibit  a  peculiar  periodicity  of 
recurrence,  while  the  passage  of  a  tube  in  the  early  morning 
reveals  the  existence  of  food-stagnation.  Just  as  haemorrhage 
is  the  most  important  of  the  various  local  symptoms,  so  the 
detection  of  a  tumour  constitutes  the  physical  sign  of  the  greatest 
moment.  The  period  at  which  a  tumour  develops  varies  in 
different  cases,  but  when  once  a  tender  growing  mass  attached 
to  the  stomach  is  discovered,  further  evidence  as  to  the  nature 
of  the  disease  may  be  regarded  as  superfluous.  In  other  cases 
equally  important  evidence  is  derived  from  the  infection  of 
organs  outside  the  stomach.  Thus,  the  liver  may  enlarge  and 
present  several  palpable  growths  in  its  substance,  or  small 
tumours  may  appear  in  the  skin  of  the  abdomen  near  the  umbili- 
cus, with,  perhaps,  a  cord-like  induration  of  the  linea  alba.     In 


DIAGNOSIS  233 

other  instances,  again,  the  pleurae  or  the  lungs  exhibit  signs  of 
disease,  ascites  or  jaundice  develops,  the  glands  above  the  left 
clavicle  become  enlarged,  or  the  veins  of  the  legs  are  affected 
by  thrombosis.  Examination  of  the  blood  always  indicates 
the  existence  of  secondary  anaemia,  the  slight  degree  of  leuco- 
cytosis  which  normally  occurs  after  meals  may  be  absent, 
the  sulphocyanide  of  potassium  in  the  saliva  tends  to  disappear, 
and  perhaps  small  particles  of  the  morbid  growth  may  be 
detected  in  the  vomit  or  the  washings  of  the  stomach. 

Early  Diagnosis 

In  addition  to  the  desirability  of  recognising  a  fatal  disease 
as  soon  as  possible,  the  recent  advances  which  have  been 
made  in  gastric  surgery  give  ground  for  the  hope  that  a  malig- 
nant growth  of  the  stomach  might  be  removed  with  success  if 
the  operation  is  undertaken  before  infection  of  the  structures 
outside  the  stomach  has  occurred.  The  question  of  '  early 
diagnosis  '  has  consequently  become  one  of  paramount  impor- 
tance, and  numerous  treatises  have  been  published  which 
purport  to  aid  in  its  elucidation.  Unfortunately,  however,  it 
would  seem  that  their  authors  are  more  concerned  with  the 
early  recognition  of  certain  physical  signs  than  of  the  disease 
from  which  they  arise.  Thus,  the  majority  of  writers  still 
centre  their  attention  upon  the  diagnostic  importance  of  a 
tumour,  and  detail  with  the  utmost  minuteness  the  methods  in 
vogue  for  its  detection  and  differential  diagnosis.  But  we  have 
already  endeavoured  to  show  that  a  palpable  tumour  is  absent 
in  nearly  one  fifth  of  all  cases  of  carcinoma  of  the  stomach, 
and  that  its  existence  bears  witness  to  the  fact  that  the  growth 
has  given  rise  either  to  an  extensive  infiltration  of  the  gastric 
wall  or  to  a  secondary  infection  of  the  great  omentum  and  lym- 
phatic glands.  It  is  obvious,  therefore,  that  while  a  tumour 
affords  conclusive  evidence  of  the  existence  of  carcinoma,  it  also 
indicates  that  the  disease  has  already  existed  for  a  considerable 
period  of  time  and  is  too  far  advanced  to  admit  of  complete 
removal.  Other  authorities  consider  that  the  solution  of  the 
difficulty  is  to  be  found  in  the  altered  state  of  the  gastric  secre- 
tion, and  affirm  that  an  absence  of  free  hydrochloric  acid  and 
the  presence  of  a  large  quantity  of  lactic  acid  after  a  test  meal 
are  pathognomonic  of  the  complaint.     On  the  other  hand,  it  has 


234  CANCER   OF  THE   STOMACH 

already  been  shown  that  not  only  are  one  or  both  these  indications 
absent  in  about  10  per  cent,  of  all  the  cases  of  gastric  carcinoma, 
and  that  those  neoplasms  which  originate  in  a  simple  nicer 
usually  exhibit  an  excess  of  hydrochloric  acid,  but  that  other 
diseases  of  the  stomach  are  occasionally  accompanied  by  similar 
changes  in  the  secretion.  Moreover,  the  chronic  gastritis  which 
is  the  immediate  cause  of  the  disappearance  of  the  hydrochloric 
acid  is  itself  only  a  secondary  effect  of  the  morbid  growth,  and 
seldom  develops  until  either  the  pylorus  has  become  contracted 
or  the  tumour  has  undergone  superficial  ulceration.  It  conse- 
quently follows  that  these  chemical  phenomena  are  at  most 
merely  confirmatory  of  the  existence  of  the  disease,  and  from 
the  point  of  view  of  early  diagnosis  their  value  is  strictly  limited. 
Xor  does  it  seem  that  those  who  rely  entirely  upon  the 
microscope  are  either  more  accurate  in  then  conclusions  or 
better  able  to  recognise  the  complaint  at  an  exceptionally 
early  period  of  its  development,  since  the  Oppler-Boas  bacillus 
does  not  appear  in  the  contents  of  the  stomach  without 
the  coexistence  of  lactic  acid,  while  minute  particles  of 
growth  or  cells  showing  irregular  mitoses  are  rarely,  if  ever, 
present  in  the  washings  of  the  organ  unless  the  disease  has 
invaded  the  mucous  membrane.  Lastly,  it  may  be  observed 
that  some  surgeons  regard  an  exploratory  laparotomy  as  the 
best  method  of  diagnosis,  while  a  few  even  advocate  the  opera- 
tion in  every  case  of  dyspepsia  that  develops  after  middle  age 
and  fails  to  subside  after  six  weeks  of  medical  treatment. 
Apart  from  the  inconvenience  which  the  adoption  of  this  sug- 
gestion would  entail  upon  several  millions  of  men  and  women 
who  from  various  causes  become  the  subjects  of  troublesome 
indigestion  at  this  period  of  life,  it  has  yet  to  be  shown  that 
digital  exploration  of  the  stomach  is  at  any  time  a  certain 
method  of  diagnosis.  All  experience  goes  to  show  that  even  after 
death  much  difficulty  is  often  experienced  in  distinguishing  a 
localised  carcinoma  of  the  gastric  wall  from  a  simple  ulcer  or 
its  scar ;  while  a  careful  comparison  of  the  conditions  found  at 
the  autopsy  with  the  apparent  discoveries  made  at  the  opera- 
tion in  a  large  series  of  cases  have  convinced  us  that  even  the 
most  experienced  surgeons  are  very  apt  to  confound  the  results 
of  inflammation,  of  simple  ulceration,  and  even  of  syphilis,  with 
malignant  growths  of  the  stomach  and  duodenum.  It  must 
therefore    be    conceded    that    as    a    rule    exploration    of    the 


DIAGNOSIS  235 

stomach  through  an  abdominal  incision  is  not  a  method  of 
diagnosis  which  can  be  recommended  either  for  its  simplicity 
or  accuracy. 

While  it  must  be  acknowledged  that  at  the  present  time  we 
do  not  possess  any  certain  means  of  recognising  the  existence 
of  carcinoma  before  it  has  infected  the  lymphatic  glands, 
it  is  possible  that  in  the  future  some  chemical  product  of 
the  morbid  growth  may  be  .discovered  in  the  secretion  of  the 
kidneys  or  in  the  saliva  which  will  render  the  early  diagnosis 
of  the  disease  a  matter  of  ease  and  certainty. 


Differential  Diagnosis 

(1)  Carcinoma  of  the  Cardia. — This  variety  has  chiefly  to 
be  distinguished  from  cicatricial  stricture  and  spasm  of  the 
cardiac  orifice.  Of  the  three,  the  malignant  affection  is  by  far 
the  most  common,  for,  out  of  every  hundred  cases  of  obstruc- 
tion at  the  lower  end  of  the  oesophagus,  about  ninety  are 
due  to  cancer,  seven  to  simple  stricture,  and  three  to  cardio- 
spasm. Carcinoma  is  rather  more  frequent  in  men  than 
women,  and  seldom  develops  before  fifty  years  of  age.  Cica- 
tricial contraction  is  usually  the  result  of  corrosive  poisoning, 
and  its  symptoms  supervene  gradually  aftsr  the  subsidence  of 
those  arising  from  inflammation  of  the  oesophagus  and 
stomach.  Very  rarely  it  results  from  a  simple  ulcer.  Chronic 
cardio-spasm  is  almost  entirely  confined  to  men,  although  a  less 
severe  form  is  sometimes  encountered  in  anaemic  and  neurotic 
women.  In  each  dysphagia  is  the  first  and  most  prominent 
symptom.  In  carcinoma  and  cicatricial  stenosis  this  increases 
in  severity,  until  regurgitation  occurs  after  every  attempt 
to  swallow  food;  but  in  cardio-spasm  it  is  apt  to  vary 
from  time  to  time,  and  regurgitation  is  rare.  Carcinoma  is 
accompanied  by  rapid  emaciation,  cachexia,  and  sometimes  by 
pain  at  the  chest,  and  in  spite  of  all  treatment  terminates 
fatally  within  nine  months.  The  fibrous  stricture  is  more 
amenable  to  local  treatment,  and  if  gastrostomy  is  performed 
life  may  be  prolonged  for  many  years ;  while  cardio-spasm 
progresses  very  slowly  and  may  persist  for  a  long  time  without 
exercising  any  serious  influence  upon  the  general  nutrition. 
In  each  complaint  the  second  deglutition  sound  is  greatly 
delayed  or  entirely  abolished,   and  a  tube  inserted   into   the 


236  CANCEE  OP   THE   STOMACH 

oesophagus  encounters  resistance  at  sixteen  to  eighteen  inches 
from  the  incisor  teeth.  In  the  organic  varieties  the  stricture 
gradually  becomes  impermeable,  but  in  the  functional  disorder 
careful  manipulation  will  often  effect  the  passage  of  the  instru- 
ment into  the  stomach.  Dilatation  of  the  oesophagus  above 
the  stricture  may  occur  in  each  instance,  and  a  small  quantity 
of  undigested  food  mixed  with  saliva  may  be  evacuated  by  the 
tube.  If  the  stricture  is  due  to  a  malignant  growth,  the  extract 
is  often  fetid,  tinged  with  blood,  and  may  contain  minute 
particles  of  the  morbid  growth,  but  in  the  non-malignant  cases 
these  evidences  of  ulceration  are  usually  lacking. 

If  the  malignant  growth  also  affects  the  fundus,  a  palpable 
tumour  may  be  detected  in  the  left  hypochondrium,  which 
requires  to  be  distinguished  from  an  enlargement  of  the  spleen, 
a  movable  kidney,  a  growth  in  the  tail  of  the  pancreas,  and 
from  a  tumour  of  the  colon  (fig.  45,  p.  173). 

(1)  An  enlarged  spleen  presents  a  sharp  edge,  a  smooth 
surface,  and  a  dull  note  upon  percussion.  Tenderness  is 
usually  absent,  and  if  the  organ  continues  to  grow  the  long 
axis  of  the  tumour  points  towards  the  opposite  iliac  fossa 
rather  than  in  the  direction  of  the  umbilicus.  Gastric  sym- 
ptoms  are   absent,  and    leuchgemia   may    often    be    detected. 

(2)  A  movable  kidney  can  be  displaced  by  pressure  to  a  much 
greater  extent  than  a  cancerous  fundus.  Its  surface  is  smooth 
and  non-tender,  its  outlines  well  defined,  and  the  percussion-note 
is  resonant,  owing  to  interposition  of  the  colon.  Gastric  sym- 
ptoms are  wanting,  and  the  other  kidney  may  also  be  loose. 

(3)  In  carcinoma  of  the  tail  of  the  pancreas  the  tumour  is 
fixed,  hard,  tender,  tympanitic  on  light  percussion,  and  rarely 
accompanied  by  special  gastric  symptoms,  unless  it  happens  to 
compress  the  cardiac  orifice  or  involve  the  stomach.  (4)  A 
palpable  tumour  of  the  colon  due  to  a  malignant  growth  is 
rare,  and  usually  consists  of  a  faecal  accumulation  above  the 
stricture.  The  mass  is  consequently  somewhat  ill-defined  in 
outline,  of  softish  consistence,  and  may  often  be  indented 
by  pressure  with  the  finger.  It  is  more  movable  in  a  lateral 
direction  than  a  tumour  of  the  fundus,  increases  very  slowly  in 
size,  and  may  completely  disappear  after  a  thorough  evacua- 
tion of  the  bowels.  The  symptoms  that  accompany  it  are 
those  of  chronic  intestinal  obstruction  rather  than  of  malignant 
disease  of  the  stomach. 


DIAGNOSIS 


237 


Table  31. — Showing  the  Peincipal  Points  of  Distinction  between  the 
Three  Varieties  of  Stricture  of  the  Cardiac  Orifice 


Symptoms 

Carcinoma 

Cicatricial  stricture 

Cardio-spasm 

1  Onset      . 

Gradual 

After       corrosive 
poisoning       or 
symptoms       of 
ulcer 

Often  sudden 

Dysphagia 

Progressive,  and  finally 

Progressive 

Often  intermit- 

complete 

tent 

Eegurgitation 

Constant    . 

Constant 

Rare 

Loss  of  flesh  . 

Rapid 

Rapid . 

Slight  or  slow 

Cachexia 

Progressive          .         .    Some  anaemia 

Absent 

Duration 

Six  to  nine  months     .  j  Varies 

Years 

Exploration  of  oeso- 

Impermeable stricture 

Stricture  ;        no 

Tube  may  pass 

phagus 

at    cardiac    orifice ; 
some   dilatation   of 
oesophagus ;  extract 
may  contain   blood 
or  cancer  tissue 

haemorrhage    . 

into  stomach 

Tumour . 

Occasionally  at  a  late 
stage 

Absent 

Absent 

Secondary   growths 

Frequent    . 

Absent 

Absent 

(2)  Carcinoma  of  the  Pylorus.— A  morbid  growth  of  the 
pylorus  is  chiefly  attended  by  the  symptoms  and  signs  of 
dilatation  of  the  stomach,  and  has  therefore  to  be  distinguished 
from  two  other  conditions  which  produce  stenosis  of  the  outlet, 
namely,  the  cicatrisation  of  a  simple  ulcer  and  adhesions 
between  the  pylorus  and  the  gall-bladder  or  liver. 

The  malignant  disease  occurs  with  equal  frequency  in  the 
two  sexes,  and  seldom  appears  before  the  age  of  forty-five. 
Cicatricial  stenosis  affects  both  sexes,  and  is  most  common 
between  thirty  and  fifty  years  of  age.  The  pyloric  obstruction 
which  results  from  cholecystitis  is  far  more  common  in  women 
than  in  men  and  develops  at  a  comparatively  early  age. 

The  previous  history  of  the  patient  is  always  of  great 
importance.  In  carcinoma  the  general  health  is  usually  excel- 
lent until  the  onset  of  the  disease  ;  in  ulcer  the  symptoms  of 
gastric  dilatation  are  preceded  by  severe  pain  after  food  and 
often  by  one  or  more  attacks  of  hsematemesis ;  while  in  disease 
of  the  gall-bladder  there  is  usually  a  history  of  severe  attacks 
of  pain,  accompanied  by  vomiting  and  shivering,  and  sometimes 
followed  by  icterus.  In  each  complaint  there  are  vomiting, 
flatulence,  acidity,  nausea,  loss  of  appetite,  and  constipation  ; 
but  these  symptoms  develop  much  more  slowly  in  the  simple 


23S  CANCEE  OF  THE   STOMACH 

than  in  the  malignant  complain t,  and  are  attended  by  less 
rapid  loss  of  flesh  and  an  absence  of  cachexia.  In  addition  to 
these  differences  of  symptomatology  there  are  three  physical 
signs  which  greatly  help  to  distinguish  the  malignant  from  the 
benign  forms  of  pyloric  stenosis. 

In  about  71  per  cent,  of  the  cases  of  carcinoma  of  the  pylorus 
a  growing  tumour  can  be  detected  by  palpation,  being  usually 
tender  on  pressure  and  often  becoming  adherent  to  the 
liver  or  other  neighbouring  organ  (p.  171).  Examination  of 
the  contents  of  the  stomach  usually  shows  an  absence  of  free 
hydrochloric  acid,  with  an  excess  of  lactic  acid  and  the  presence 
of  the  Oppler-Boas  bacillus ;  while  the  microscope  may  reveal 
particles  of  cancer  tissue  or  epithelial  cells  which  exhibit 
atypical  mitoses  (p.  161).  At  a  later  stage  secondary  deposits 
are  frequently  found  in  the  liver,  peritoneum,  or  skin  of  the 
abdomen. 

Pyloric  stenosis  due  to  ulcer  is  accompanied  by  hyperchlor- 
hydria  without  either  lactic  acid  or  the  Oppler-Boas  bacillus, 
and  is  rarely  attended  by  a  palpable  tumour  ;  while  in  cases  of 
adhesions  between  the  pylorus  and  the  gall-bladder  free  hydro- 
chloric acid  may  usually  be  detected  in  the  gastric  contents  and 
the  organic  acid  is  absent.  As  a  rule  these  several  distinctions, 
taken  in  conjunction  with  the  much  longer  duration  of  the 
benign  diseases,  and  their  greater  amenability  to  treatment, 
allow  the  latter  to  be  readily  distinguished  from  the  malignant 
complaint ;  but  occasionally  both  a  simple  ulcer  and  pyloric 
adhesions  are  associated  with  a  palpable  tumour,  which  greatly 
complicates  their  diagnosis. 

(a)  It  is  only  in  very  exceptional  cases  that  an  abnormal 
degree  of  thickening  at  the  base  of  an  ulcer  gives  rise  to 
a  tumour  in  the  region  of  the  pylorus.  In  such  the  mass 
usually  resembles  a  walnut  in  size  and  shape,  or  takes  the  form 
of  a  hard  ridge  or  plate ;  but  sometimes  it  is  so  large  as  to 
produce  a  tumour  visible  to  the  naked  eye. 

Thus,  Clarke  has  recorded  the  case  of  a  man,  forty-five 
years  of  age,  who  had  suffered  for  some  time  from  pain  after 
food  and  vomiting.  The  right  side  of  the  epigastrium  was 
swollen,  and  presented  a  rounded  tumour  about  the  size  of  an 
orange.  After  death,  which  occurred  from  peritonitis,  the 
pyloric  end  of  the  stomach  was  found  to  be  occupied  by  a 
tumour  the  size  of  two  fists,  to  which  the  neighbouring  viscera 


DIAGNOSIS  239 

were  adherent.  The  mass  was  composed  of  pale  tough  fibrous 
tissue,  which  surrounded  two  deep  ulcers  with  ragged  walls. 
Microscopic  examination  showed  that  the  tumour  was  com- 
posed entirely  of  inflammatory  tissue.  Three  or  four  similar 
cases  have  come  under  our  own  observation,  of  which  the 
following  is  a  good  example. 

Case  XX.  A  middle-aged  woman  was  admitted  into  hospital  for 
cancer  of  the  stomach.  She  was  greatly  emaciated  and  cachectic, 
and  suffered  from  constant  retching  and  vomiting.  The  illness  was 
supposed  to  have  lasted  for  a  year,  but  there  was  no  history  of  hsemat- 
emesis  or  melaena.  On  examination  the  stomach  was  found  to  be 
greatly  dilated,  and  its  peristaltic  movements  were  plainly  visible 
through  the  thin  abdominal  walls.  Immediately  above  and  to  the 
right  of  the  navel  there  was  a  prominent  tumour  the  size  of  a  large 
egg,  which  moved  with  respiration,  was  dull  on  percussion,  and  very 
tender.  These  signs,  taken  in  conjunction  with  the  general  appear- 
ance of  the  patient,  seemed  to  warrant  a  diagnosis  of  carcinoma  of  the 
pylorus,  but  an  examination  of  the  vomit  showed  that  it  contained  an 
excess  of  free  hydrochloric  acid  and  no  lactic  acid.  The  case  was 
consequently  diagnosed  as  one  of  chronic  ulcer  with  inflammatory 
thickening.  At  the  necropsy  a  deep  ulcer  was  found  in  tbe  posterior 
wall  of  the  stomach,  close  to  the  pylorus,  surrounded  by  great 
induration  of  the  tissues.    No  signs  of  carcinoma  could  be  discovered, 

(b)  All  varieties  of  pyloric  stenosis  are  liable  to  be  associated 
with  the  intermittent  appearance  of  a  tumour  during  the  peri- 
staltic contraction  of  the  hypertrophied  gastric  wall.  This 
condition,  however,  persists  for  only  two  or  three  minutes  at  a 
time,  can  often  be  seen  as  well  as  felt,  and  completely  dis- 
appears as  soon  as  the  gastric  movement  ceases. 

(c)  A  gall-bladder  adherent  to  the  pylorus  seldom  gives  rise 
to  a  tumour  unless  it  happens  to  contain  a  large  calculus. 
When  this  is  the  case  a  hard  non-tender  mass  may  be  detected 
in  the  right  hypochondriurn,  in  the  neighbourhood  of  the  ninth 
costal  cartilage,  which  moves  downwards  upon  inspiration  but 
is  incapable- of  lateral  displacement.  Distension  of  the  stomach 
with  gas  shows  that  the  pylorus  is  fixed  to  the  under  surface  of 
the  liver,  the  edge  of  which  organ  may  sometimes  be  felt  at  the 
margins  of  the  tumour.  Less  frequently  a  gumma  or  hydatid 
of  the  liver  is  the  cause  of  the  gastric  adhesion,  and  the  tumour 
then  presents  the  general  features  characteristic  of  these 
diseases. 


240 


CANCEE  OP  THE   STOMACH 


Table  32.  — The  Differential  Diagnosis  of  the  Principal  Conditions  which 
give  rise  to  Stenosis  of  the  Pylorus 


Symptoms 

Carcinoma 

Ulcer 

Pyloric  adhesions 

History 

Loss  of  flesh 
Cachexia     . 
Hffimatemesis 

No  previous  disease   . 

Progressive  and  severe 

Present 

Often  coffee-grounds , 

Symptoms     of 

ulcer 
Moderate 
Absent     . 
Occasional  and 

Biliary  colic  or  jaun- 
dice 
Varies 
Absent 
Absent 

Gastric  contents. 
Tumour 

No    free  HC1;    lactic 
acid ;     Oppler-Boas 
bacillus  ;      perhaps 
atypical  epithelium 

Usual.  Eapid  growth ; 
tender;  often  mov- 
able 

severe 
Excess  of  HC1 

Very  rare 

Free  HC1 ;   no   lactic 
acid 

Occasional.        Hard  ; 
painless ;    fixed    to 
liver ;    no    increase 

Metastases  . 
Treatment  . 

Usual 

No  effect    . 

Absent     . 
Good  effect 

in  size 
Absent 
Good  effect 

(3)  Carcinoma  of  the  Body  of  the  Stomach. — A  growth 
which  involves  the  surfaces  or  curvatures  of  the  stomach  with- 
out implication  of  an  orifice  is  often  accompanied  by  such 
severe  pain,  vomiting,  and  hsematemesis  that  its  differential 
diagnosis  from  simple  ulcer  may  be  a  matter  of  considerable 
difficulty. 

It  is  usually  stated  that  simple  gastric  ulcer  is  a  disease  of 
early  adult  life,  and  carcinoma  one  of  middle  or  advanced  age, 
and  that  the  former  is  most  frequent  in  women  and  the  latter 
in  men.  If  these  statements  refer  solely  to  the  acute  variety  of 
gastric  ulcer,  the  distinctions  they  imply  are  correct,  but  if  they 
include  the  ordinary  chronic  form  of  the  complaint,  they  are  not 
only  incorrect  but  actually  misleading.  We  have  shown  else- 
where that  more  than  one  half  of  the  cases  of  chronic  ulcer 
commence  between  thirty  and  fifty  years  of  age,  and  that  the 
disease  is  more  common  at  this  period  in  men  than  in  women, 
while  carcinoma  is  by  no  means  infrequent  between  thirty  and 
forty,  and  is  equally  prevalent  in  the  two  sexes.  We  lay  special 
stress  upon  these  facts,  because  we  have  known  many  serious 
errors  of  diagnosis  to  ensue  from  an  implicit  reliance  upon  the 
supposititious  differences  in  the  age  and  sex  incidence  of  the  two 
diseases. 

The  chief  points  of  distinction  between  chronic  ulcer  and 
cancer   are  as   follows  :     (a)  In    cancer,    debility    and   loss   of 


DIAGNOSIS  241 

flesh  usually  precede  the  local  phenomena,  while  in  ulcer  they 
rarely  appear  until  a  late  stage  of  the  disease,  (b)  In  the 
former  the  pain  is  less  dependent  upon  food,  is  more  diffuse, 
and  shows  a  tendency  to  increase  and  to  become  constant, 
(c)  Nausea  is  most  frequent  in  cancer,  and  retching  and  vomiting 
often  occur  when  the  stomach  is  devoid  of  food.  In  ulcer,  on 
the  other  hand,  emesis  usually  takes  place  at  the  height  of  the 
painful  crisis,  and  is  followed  by  immediate  relief,  (d)  Profuse 
ha3matemesis  is  rare  in  the  malignant  complaint,  while  the 
rejection  of  small  quantities  of  altered  blood  is  frequently 
observed.  In  ulcer  the  haemorrhage  occurs  at  irregular 
intervals  and  is  very  abundant,  (e)  Anorexia  is  an  early  and 
progressive  symptom  in  carcinoma,  and  the  tongue  is  often  foul, 
while  in  ulcer  the  appetite  is  usually  preserved,  although  the 
patient  is  afraid  to  indulge  it,  and  the  tongue  is  red  and  clean. 
(/)  Free  hydrochloric  acid  is  rarely  present  in  the  vomit  or  the 
contents  of  the  stomach  in  cases  of  carcinoma,  while  lactic  acid 
may  exist  in  excess.  In  ulcer  the  mineral  acid  is  usually 
increased  and  the  organic  acid  absent,  (g)  Microscopical 
examination  of  the  vomit  or  washings  of  the  stomach  in  malig- 
nant disease  may  detect  the  Oppler-Boas  bacillus,  cancer  cell- 
nests,  or  epithelial  cells  showing  irregular  mitoses,  (h)  Leuco- 
cytosis  after  meals  is  often  absent  in  cases  of  cancer,  but  is  always 
present  and  may  be  slightly  increased  in  chronic  ulcer,  (i)  A 
tumour  connected  with  the  stomach  is  the  rule  in  cancer,  but 
the  exception  in  ulcer.  (J)  In  carcinoma  the  sulphocyanide  of 
potassium  in  the  saliva  rapidly  diminishes  and  eventually  dis- 
appears, while  in  ulcer  the  salt  can  be  detected  until  a  late  stage 
of  the  complaint,  (k)  A  milk  diet  often  increases  the  abdominal 
pain  or  discomfort  of  the  former  complaint,  and  the  patient 
continues  to  lose  both  flesh  and  strength  when  restricted  to 
liquids ;  in  the  latter,  abstention  from  solid  food  is  followed 
by  the  immediate  amelioration  of  the  symptoms,  and  milk 
almost  always  agrees  well.  (I)  Carcinoma  usually  gives  rise  to 
secondary  deposits  in  the  liver,  peritoneum,  or  skin  of  the 
abdomen,  to  enlargement  of  the  glands  above  the  clavicle,  or  to 
venous  thrombosis,  and  usually  runs  its  course  in  less  than 
twelve  months.  In  ulcer  the  physical  signs  remain  unaltered 
and  the  symptoms  may  persist  for  many  years. 

A  carcinomatous  tumour  of  the  body  of  the  stomach  has  to 
be  distinguished  from  that  produced  by  a  foreign  body  in  the 


242  CANCEE  OF  THE   STOMACH 

viscus,  from  the  pancreas  in  a  normal  or  diseased  state,  from  a 
retro-peritoneal  cyst,  and  from  a  tumour  of  the  colon. 

A  hair-ball  constitutes  the  variety  of  foreign  body  most 
liable  to  be  mistaken  for  a  growth  of  the  gastric  wall.  This 
interesting  condition,  however,  is  practically  confined  to  young 
women,  and  usually  commences  before  the  age  of  puberty. 
The  mass  is  hard,  superficial,  dull  on  percussion,  painless,  very 
movable,  and  of  extremely  slow  growth.  The  symptoms 
which  accompany  it  are  those  of  chronic  dyspepsia,  and  careful 
inquiry  will  usually  elicit  a  history  of  hair-swallowing  (see 
Part  II.). 

When  great  emaciation  exists  and  adhesion  of  the  pylorus 
to  the  liver  has  induced  a  dislocation  downwards  of  the  dilated 
stomach,  the  uncovered  pancreas  may  sometimes  be  felt  as  a 
hard  transversely  situated  mass  just  above  the  umbilicus.  The 
apparent  tumour,  however,  does  not  move  with  respiration  like 
a  gastric  growth,  is  incapable  of  displacement  by  the  hand,  does 
not  increase  in  size,  is  deeply  situated  in  the  abdomen,  and  is 
found  to  lie  above  the  lesser  curvature  of  the  stomach. 

A  cyst  of  the  pancreas  usually  comes  forward  between  the 
great  curvature  of  the  stomach  and  the  transverse  colon.  Over 
its  exposed  portion  the  percussion-note  is  dull,  while  elsewhere 
the  superimposed  stomach  or  bowel  gives  rise  to  a  resonant  note. 
The  outlines  of  the  mass  are  ill-defined,  the  general  shape  is 
globular,  and  no  movement  can  be  detected  upon  respiration  or 
pressure.  Inflation  of  the  stomach  shows  that  viscus  to  be  in 
front  of  or  above  the  tumour,  while  the  symptoms  and  signs  of 
gastric  carcinoma  are  invariably  absent. 

In  those  rare  cases  where  a  small  cyst  forms  in  the  head  of 
the  pancreas  and  compresses  the  second  part  of  the  duodenum, 
the  symptoms  of  gastric  dilatation,  combined  with  the  detection 
of  a  tumour,  may  give  rise  to  much  difficulty  of  diagnosis. 

Case  XXI.  A  man,  sixty-five  years  of  age,  was  admitted  into 
hospital  under  our  cai^e  for  hasmatemesis.  He  stated  that  about  two 
years  previously  he  had  been  attacked  by  severe  pain  in  the  stomach 
and  sickness,  which  had  recurred  on  several  occasions  but  had  never 
been  followed  by  jaundice.  Two  days  before  admission  he  had 
vomited  a  large  quantity  of  bright  blood  after  suffering  for  some  time 
from  discomfort  and  distension  after  food.  On  examination  the 
stomach  was  found  to  be  much  dilated,  and  just  above  and  to  the 
right  of  the  umbilicus  a  hard,  smooth,  and  fixed  tumour  could   be 


DIAGNOSIS 


243 


felt.  At  certain  times  the  percussion-note  over  the  swelling  was  dull, 
while  at  others  a  splashing  sound  was  elicited.  Inflation  of  the 
stomach  and  colon  neither  affected  the  position  of  the  tumour  nor  its 
percussion-note.  After  ten  weeks'  treatment  he  was  found  to  have 
become  very  thin,  and  still  suffered  from  attacks  of  pain  and  vomiting. 
A  surgeon  was  therefore  asked  to  make  an  attempt  to  relieve  the 
pressure  on  the  duodenum.  At  the  operation  the  tumour  was  found 
to  be  situated  deeply  behind  the  small  intestine,  and  was  so  hard  and 
fixed  that  a  diagnosis  of  carcinoma  was  given  and  the  wound  was 
closed.     Death  occurred  next  day. 


Fig.  53. — Drawing  of  the  posterior  wall  of  a  stomach,  showing  a  large 
chronic  ulcer,  through  which  the  pancreas  projects  in  the  form  of  a 
tumour.     (London  Hospital  Museum.) 

Necropsy.  The  head  of  the  pancreas  was  occupied  by  a  cyst  the 
size  of  a  Tangerine  orange,  which  had  pressed  upon  and  partially 
obstructed  the  duodenum.  The  cyst  contained  a  quantity  of  brownish 
fluid,  but  no  connection  between  its  cavity  and  the  pancreatic  duct 
could  be  found.  No  ulcer  or  cicatrix  existed  in  the  stomach  or 
duodenum,  and  there  was  no  evidence  of  carcinoma  in  any  organ. 

In  very  rare  cases  the  pancreas  projects  into  the  cavity  of  the 
stomach  through  the  floor  of  a  large  chronic  ulcer,  and  gives 
rise  to  a  palpable  tumour. 

E  2 


244  CANCEE  OF  THE   STOMACH 

Kollmar  has  recorded  the  case  of  a  man  who  died  with 
extreme  cachexia,  an  abdominal  tumour,  and  other  signs  of 
cancer  of  the  stomach.  At  the  necropsy  the  naked-eye  appear- 
ances of  the  disease  seemed  to  confirm  the  diagnosis,  but  when 
the  tumour  was  incised  it  was  found  to  consist  of  a  pot-shaped 
ulcer  of  the  stomach  with  greatly  thickened  edges,  through  the 
base  of  which  the  head  of  the  pancreas  projected.  If  a  tumour 
of  this  description  can  occasionally  puzzle  the  pathologist,  it  is 
hardly  surprising  that  the  surgeon  is  not  infrequently  confused 
by  the  condition  which  he  detects  upon  digital  exploration  of 
the  stomach.  The  difficulties  that  may  attend  this  method  of 
diagnosis  are  well  illustrated  by  a  case  cited  by  Palawski,  where 
an  exploratory  operation  was  undertaken  on  account  of  con- 
tinuous pain,  vomiting,  and  heematemesis.  When  the  abdomen 
was  opened  the  stomach  was  found  to  be  adherent  to  the 
neighbouring  viscera,  and  the  retro-peritoneal  glands  were 
enlarged.  The  finger  was  then  inserted  through  an  incision  in 
the  anterior  wall  of  the  stomach,  and  a  large  cauliflower  growth 
was  detected  upon  its  posterior  surface.  Carcinoma  was 
accordingly  diagnosed  and  the  wound  closed ;  but  at  the 
necropsy  the  supposititious  growth  was  found  to  consist  of  the 
pancreas,  which  projected  through  the  base  of  a  simple  chronic 
ulcer. 

Cysts  of  the  lesser  cavity  of  the  peritoneum  or  of  the 
posterior  wall  of  the  stomach  are  very  rare.  They  are  freely 
movable,  painless,  smooth,  of  very  slow  growth,  and  the  pain 
and  vomiting  to  which  they  occasionally  give  rise  are  dependent 
upon  stretching  of  the  pyloric  end  of  the  viscus  or  of  the 
duodenum  over  the  surface  of  the  sac  (Part  II.,  Chap.  VI.). 

Much  more  difficult  is  the  diagnosis  of  a  malignant  tumour 
of  the  great  curvature  from  a  fsecal  mass  in  the  colon.  Not 
only  are  the  two  organs  in  close  proximity,  but  a  functional 
disturbance  of  the  one  is  always  accompanied  by  a  disorder  of 
the  other ;  while  in  the  majority  of  the  cases  the  neoplasm  of  the 
stomach  contracts  adhesions  with  or  actually  extends  into  the 
bowel.  In  both  conditions  the  tumour  is  placed  transversely 
in  the  abdomen,  is  irregular  in  outline,  tender,  freely  movable, 
and  comparatively  dull  on  percussion.  It  consequently  happens 
that  carcinoma  of  the  great  curvature  is  frequently  mistaken 
for  a  fsecal  accumulation  in  the  colon,  and  vice  versa.  As  a 
rule,  however,  pain,  vomiting,  and  emaciation  are  much  less 


DIAGNOSIS 


245 


marked  in  a  case  of  faecal  tumour  than  in  the  gastric  disease, 
while  the  stomach  during  digestion  presents  a  normal  secretion 
of  hydrochloric  acid.  The  colonic  tumour  is  seldom  attended 
by  spontaneous  pain,  is  of  slower  growth,  and  steady  pressure 
with  the  finger  may  produce  pitting  of  its  substance.  In  most 
cases  also  the  tumour  is  diminished  or  removed  by  the  continued 
use  of  aperients  and  large  enemata. 


Table  33, 


-The  Differential  Diagnosis  of  Carcinoma  and  Chronic  Ulcer 
of  the  Stomach 


Symptoms 

Carcinoma 

Ulcer 

Pain 

Constant,  dull  or  lancinating ; 

Severe,  paroxysmal ;  increased 

increased  by  food  and  pres- 

by solid  food,    relieved   by 

sure 

milk  diet 

Vomiting 

Frequent ;  retching  and  nau- 

Occasional;     during    painful 

sea  ;   affords  little  relief  to 

crisis ;  relieves  pain 

pain 

Haematemesis 

Frequent ;  small  quantities  of 
coffee-ground  vomit 

Occasional  and  profuse 

Appetite 

Diminished  or  absent 

Good,  unless  vomiting  severe 

Colour   . 

Progressive  cachexia 

Ansemia  proportionate  to  loss 
of  blood 

Loss  of  flesh . 

Eapid  and  continuous     . 

Gradual 

Gastric     con- 

Much mucus ;    no  free  HC1 ; 

Eapid    digestion;    free    HC1, 

tents 

lactic  acid  present ;  Oppler- 

perhaps  in  excess ;  no  lactic 

Boas  bacillus  ;  perhaps  cha- 

acid 

racteristic  cells 

Saliva    . 

Gradual     disappearance      of 
sulphocyanide  of  potassium 

Sulphocyanide  normal 

Physical  signs 

Tumour       connected       with 

Tender   spot  in  epigastrium; 

stomach,   painful,    increas- 

tumour very  rare 

ing  in  size ;  thrombosis  of 

veins ;  secondary  deposits 

(4)  The  Anaemic  Form. — Carcinoma  of  the  stomach,  when 
accompanied  during  its  early  stages  by  intense  ansemia,  may  be 
readily  confused  with  pernicious  ansemia,  and  sometimes  even 
with  leucocythaemia. 

From  the  former  it  is  chiefly  distinguished  by  the  pro- 
minence of  certain  constitutional  symptoms  and  the  lesser 
importance  of  its  blood  changes.  Loss  of  flesh  and  strength 
accompanies  the  malignant  complaint  from  the  outset,  and  the 
temperature  of  the  body  is  rarely  elevated  more  than  one  or 
two  degrees  at  night.  In  pernicious  anaemia  the  patient  often 
grows  fat,  dyspnoea  and  palpitation  are  experienced  upon 
exertion,  and  periodic  attacks  of  fever  are  the  rule.  In  both 
there  may   be   excessive   thirst   and   want    of   appetite,  with 


246  CANCEE  OF  THE   STOMACH 

flatulence  and  discomfort  after  meals  and  occasional  vomiting  ; 
but  in  carcinoma  these  symptoms  steadily  progress,  while  in 
pernicious  anaemia  a  temporary  improvement  in  the  quality  of 
the  blood  is  accompanied  by  a  corresponding  amelioration  of 
the  dyspepsia  and  a  return  of  the  appetite.  The  administra- 
tion of  iron  and  arsenic  in  the  gastric  disease  greatly  increases 
the  symptoms  of  dyspepsia,  without  producing  any  beneficial 
effect  on  the  condition  of  the  blood.  Exploration  of  the  stomach 
with  a  tube  during  the  period  of  digestion  will  often  reveal  the 
presence  of  altered  blood  in  carcinoma,  while  the  gastric 
contents  exhibit  an  excess  of  lactic  acid,  but  no  free  hydrochloric 
acid.  In  pernicious  ansemia  the  mineral  acid  is  also  apt  to  fail, 
but  lactic  acid  fermentation  is  rare  and  haemorrhage  never 
occurs.  The  blood  in  gastric  cancer  shows  a  marked  deficiency 
of  red  corpuscles,  but  their  number  rarely  falls  below  one  and  a 
half  million  per  cubic  millimetre ;  poikilocytosis  is  rare,  and 
megaloblasts  are  never  encountered.  After  a  few  months  a 
tumour  can  usually  be  discovered  in  connection  with  the 
stomach,  or  secondary  deposits  are  detected. 

Leuchgemia  with  a  palpable  enlargement  of  the  spleen  is 
very  rare  in  carcinoma  of  the  stomach,  but  when  it  exists  the 
absolute  exclusion  of  leucocythsemia  is  practically  impossible. 
In  most  of  the  cases,  however,  the  malignant  disease  shows 
itself  by  the  development  of  .a  gastric  tumour  and  dilatation  of 
the  stomach,  or  by  the  presence  of  gastric  symptoms  associated 
with  a  failure  in  the  secretion  of  hydrochloric  acid. 

(5)  The  Ascitic  Form. — In  this  variety  the  early  develop- 
ment of  ascites,  with  the  frequent  absence  of  gastric  symptoms, 
renders  the  disease  liable  to  be  mistaken  for  tubercular  peritonitis 
or  cirrhosis  of  the  liver. 

Carcinoma  of  the  peritoneum  may  occur  either  in  the  form 
of  numerous  discrete  growths  of  considerable  size  or  as  a 
miliary  affection  of  the  serous  membrane.  In  the  former  case 
examination  of  the  abdomen  reveals  the  existence  of  several 
tumours,  whose  tenderness  and  rapidity  of  growth  are  suggestive 
of  their  malignant  nature,  while  in  the  latter  no  tumour  can 
be  detected  either  by  palpation  or  digital  exploration  of  the 
rectum.  In  both  instances  the  effusion  may  be  unaccompanied 
by  pain  or  vomiting  for  two  or  three  months,  and  the  principal 
symptoms  consist  of  distension  after  meals  with  excessive 
flatulence.     Careful  examination,  however,  will  usually  show 


DIAGNOSIS  247 

that  the  constitutional  symptoms  are  more  pronounced  than  in 
other  forms  of  ascites.  The  soft  parts  undergo  rapid  wasting, 
the  lips  and  conjunctivae  are  markedly  anseniic,  and  although 
the  temperature  is  subnormal,  the  patient  usually  expresses  an 
aversion  to  food.  The  skin  is  loose  and  dry,  the  secretion  of 
urine  is  diminished,  and  oedema  of  the  legs  and  thrombosis  of 
the  saphenous  or  femoral  veins  frequently  occur.  After  a  vari- 
able interval  attacks  of  abdominal  pain  are  apt  to  supervene 
and  to  prove  severe,  while  in  most  cases  nausea,  vomiting,  and 
haematemesis  are  observed.  The  physical  signs  vary  according 
to  the  size  of  the  peritoneal  growths.  When  these  are  com- 
paratively few  in  number,  and  principally  affect  the  great 
omentum  or  the  more  superficial  portions  of  the  serous  mem- 
brane, one  or  more  discrete  tumours  may  be  detected  on 
palpation,  which  rapidly  increase  in  size,  are  tender  on  pres- 
sure, dull  on  percussion,  and,  though  movable  with  respiration, 
gradually  become  fixed  by  adhesions  to  the  neighbouring  coils 
of  bowel.  Digital  exploration  of  the  pelvis  will  also  detect 
one  or  more  nodular  growths  in  the  pouch  of  Douglas  or 
in  the  wall  of  the  vagina  or  bowel,  which  are  apt  to  press 
upon  the  bladder  and  to  cause  frequent  and  difficult  micturi- 
tion. Subsequently  small  metastases  develop  in  the  neighbour- 
hood of  the  umbilicus,  or  infiltration  of  the  linea  alba  occurs. 
In  miliary  carcinoma  of  the  peritoneum  the  growths  are 
too  small  to  form  palpable  tumours,  and  the  most  important 
indications  of  the  disease  arise  from  the  contraction  of  the 
mesentery  and  transverse  mesocolon  with  which  it  is  usually 
accompanied.  In  such  the  percussion-note  over  the  front  of 
the  abdomen  is  uniformly  dull  instead  of  being  resonant,  while 
posteriorly  the  note  over  the  lumbar  region  is  much  clearer  on 
one  side  than  on  the  other,  owing  to  the  adhesion  of  the  mass 
of  retracted  intestine  to  the  back  of  the  abdominal  cavity. 

Examination  of  the  fluid  withdrawn  by  a  syringe  will  often 
materially  aid  the  diagnosis.  In  simple  ascites  the  quantity  of 
albumin  is  usually  less  than  2^  per  cent.,  while  in  cancerous 
peritonitis  it  amounts  to  3-4  per  cent.,  and  is  often  as  high  as 
5-6  per  cent.  When  the  growths  are  soft  and  numerous  the 
fluid  is  often  stained  with  blood,  while  in  certain  cases  obstruc- 
tion of  the  thoracic  duct  or  lacteals  gives  rise  to  chylous  ascites. 
When  the  sediment  is  examined  by  the  microscope,  groups  of 
cancer  cells  may  sometimes  be  detected,  and  even  the  existence 


248 


CANCER   OF  THE   STOMACH 


of  colloid  carcinoma  may  be  recognised  by  the  characteristic 
changes  in  the  cells.  More  frequently  only  a  few  epithelial 
cells  are  obtained  by  the  use  of  the  centrifuge,  which  exhibit 
budding  or  irregular  forms  of  mitosis.  Lastly,  it  is  often 
observed  that  at  the  seat  of  puncture  a  small  hard  tumour 
develops  from  invasion  of  the  subperitoneal  tissue  by  carcinoma. 
Tubercular  peritonitis  in  the  adult  is  usually  associated  with 
fever.  Pain  is  often  a  notable  feature  of  the  complaint  in  its 
early  stages,  and  diarrhoea  is  apt  to  alternate  with  constipation. 
Loss  of  flesh  and  strength  is  less  rapid  than  in  carcinoma  ; 
profuse  perspirations  occur  at  night,  and  rigors  are  not  infre- 
quent. The  tumour  is  usually  situated  across  the  epigastrium, 
is  nodular,  comparatively  dull  on  percussion,  rarely  very  tender, 
and  of  slow  growth.  Tumours  are  rarely  detected  in  the  pouch 
of  Douglas  or  in  the  tissues  of  the  rectum  or  vagina,  and  in 
most  instances  signs  of  secondary  inflammation  of  the  pleura 
or  lung  manifest  themselves  after  a  few  weeks.  Ascites  from 
cirrhosis  of  the  liver  is  usually  preceded  by  symptoms  of  chronic 
gastritis,  and  is  accompanied  by  haemorrhoids.  Abdominal  pain 
is  absent,  there  are  no  peritoneal  tumours,  and  the  floating 
intestines  produce    a   resonant    note    on   percussion    over   the 


Table  34. — The  Differential  Diagnosis  of  the  Pbixcipal  Diseases 

ACCOMPANIED    BY     EaBLT    ASCITES 


Symptoms 

Carcinoma  of  peritoneum 

Tubercle  of  peritoneum 

Cirrhosis  of  liver 

Previous     his- 

Sometimes   pain    after 

Occasionally 

Abuse  of  alcohol ; 

tory 

food  or  vomiting 

phthisis 

gastritis 

Onset 

Often  rapid   . 

Gradual 

Gradual 

Pain    and   vo- 

In later  stages 

Often  at  commence- 

Pain absent 

miting 

ment 

Loss  of  flesh  . 

Rapid    .... 

Gradual 

Slight 

1  Cachexia 

Marked 

Ansemia 

Absent 

Appetite 

Diminished  or  absent    . 

Faii- 

Fair 

Temperature  . 

Subnormal    . 

Elevated         ... 

Xormal 

Hamiorrhoids 

Absent  .... 

Absent   . 

Usually  present 

Tumour 

Frequent  ;        multiple ; 

Epigastric  ;    nodu- 

Large liver 

rapid  growth ;  affects 

lar;  slow  growth 

pelvis 

Abdomen 

Often  dull  on  percussion 

Signs  of  free  fluid  . 

Signs     of      free 

in  front,  resonant  in 

fluid 

loin 

Fluid      . 

Very  albuminous ;  per- 

Cloudy;       perhaps 

Clear 

haps  blood  or  chyle ; 

tubercle  bacilli 

cancer  cells 

Metastases 

Abdominal    wall,   linea 

Tubercular  disease 

Absent 

alba,  pleura? 

of    intestines    or 
lungs 

Duration 

Three  to  six  months 

Varies 

Years 

DIAGNOSIS 


249 


umbilical  region.  The  liver  is  found  to  be  enlarged  and  hard, 
and  a  history  of  over-indulgence  in  alcohol  can  usually  be 
obtained. 

(6)  The  Dyspeptic  Form. — When  a  malignant  growth  of  the 
stomach  is  merely  accompanied  by  symptoms  of  indigestion, 
and  for  several  months  presents  no  indications  of  a  tumour  or 
of  gastric  dilatation,  it  is  very  apt  to  be  confused  with  chronic 
gastritis  or  nervous  dyspepsia. 

Chronic  gastritis  may  occur  at  any  age  and  in  either  sex. 
In  the  great  majority  of  cases  there  is  a  history  of  abuse  of 
alcohol,  or  there  are  signs  of  disease  in  the  lungs,  heart,  liver, 
or  kidneys.  Pain  after. food  is  rare,  but  the  patient  experiences 
fulness  and  discomfort  during  the  period  of  digestion,  accom- 
panied by  flatulence,  acid  eructations,  and  nausea.  Vomiting 
may  occur  after  meals,  but  it  is  also  frequent  in  the  early  morn- 
ing before  breakfast,  when  an  attack  of  retching  causes  the 
rejection  of  ropy  mucus.  The  appetite  is  diminished  but  not 
lost,  there  is  much  thirst,  and  the  tongue  is  usually  large,  pale, 
furred,  and  indented  by  the  teeth.  Constipation  is  apt  to  alter- 
nate  with    diarrhoea,    and    the   urine   is   loaded   with   urates. 


Table  35. — Showing  the  Chief  Points  of  Distinction  between  Carcinoma, 
Chronic  Gastritis,  and  Nervous  Dyspepsia 


Symptoms 

Carcinoma 

Chronic  gastritis 

Nervous  dyspepsia 

Onset 

Gradual     . 

Preceded      by     alco- 
holism, phthisis,  or 
kidney  disease 

Often  sudden 

Pain 

Varies ;     usually    in- 

Rarely   severe ;     dis- 

Paroxysmal;  often 

creased  by  food 

comfort    or  oppres- 

very severe 

Vomiting 

Usually   after    meals 

sion 
After     meals     or    in 

Often  absent 

or  in  early  morning 

early  morning 

Hsematemesis 

Frequent ;    in    small 
quantity 

Rare  .... 

Absent 

Appetite  . 

Diminished  or  absent 

Diminished 

Varies 

Bowels    . 

Constipation 

Occasional  attacks  of 

Often       lienteric 

diarrhoea 

diarrhoea 

Loss  of  flesh   . 

Progressive  and  severe 

Slight 

Varies  with   ap- 
petite 

Colour     . 

Progressive  cachexia 

Sallow 

Moderate  anaemia 

Gastric       con- 

No free   HC1 ;    lactic 

Diminished         HC1 ; 

HC1  often   exces- 

tents 

acid 

no  lactic  acid 

sive 

Physical  signs 

Dilatation  of  stomach 

Some      gastreetasis  ; 

Often  absent 

or  tumour  in    later 

no    tumour ;    piles ; 

stage ;        secondary 

ascites  in  late  stage 

deposits;  thromboses 

Treatment 

No  avail    . 

Symptoms  abate 

Varies 

250  CANCEE  OF  THE   STOMACH 

Unless  cirrhosis  of  the  liver  is  present,  hsematemesis  never 
occurs.  Some  degree  of  gastrectasis  may  be  detected,  but 
there  is  no  tumour,  and  the  gastric  contents  are  usually  devoid 
of  lactic  acid.  The  symptoms  subside  to  a  great  extent  under 
treatment. 

The  term  '  nervous  dyspepsia  '  includes  a  large  number  of 
disorders  arising  from  a  functional  disturbance  of  the  stomach 
or  bowel.  In  every  case,  however,  the  constitutional  sym- 
ptoms of  carcinoma  are  lacking  :  pain,  when  it  exists,  displays 
paroxysmal  characters ;  vomiting  is  infrequent,  there  is  no 
abdominal  tumour,  and  free  hydrochloric  acid  may  usually  be 
detected  in  the  contents  of  the  stomach. 


251 


CHAPTER   X 

TREATMENT 

General  Measures. — The  well-known  fatality  and  popular 
dread  of  cancer  render  it  advisable  that  very  guarded  terms 
should  be  employed  in  the  designation  of  the  complaint  until 
the  diagnosis  can  be  made  with  certainty.  This  is  the  more 
important  as  the  mental  depression  which  invariably  accom- 
panies it  is  often  replaced  by  actual  melancholia  when  the 
patient  realises  the  true  nature  of  his  malady,  and  not  only  is 
the  duration  of  life  curtailed  by  his  refusal  to  partake  of  food  or 
to  undergo  the  usual  palliative  treatment,  but  it  may  be  cut  pre- 
maturely short  by  suicide.  We  have  known  several  instances  in 
which  the  patient  destroyed  himself  a  few  days  after  being  in- 
formed that  he  was  suffering  from  cancer  of  the  stomach.  So  far 
as  may  be  consistent  with  insuring  his  appreciation  of  the  serious 
nature  of  his  disease,  it  is  therefore  wise  to  avoid  the  use  of  such 
popular  terms  as  '  cancer,'  '  growth,'  or  '  malignant  disease.' 

During  the  early  stages  of  the  complaint  the  patient  should 
be  encouraged  to  perform  his  usual  avocations,  and  when 
this  becomes  impossible  it  is  better  that  he  should  dress  and 
recline  upon  a  couch  than  remain  in  bed.  Change  of  air  is 
seldom  advisable,  since  any  slight  benefit  that  might  accrue 
from  a  bracing  atmosphere  hardly  compensates  for  the  loss  of 
home  comforts  entailed  by  residence  in  an  hotel  or  lodging- 
house.  When  the  stomach  is  much  dilated,  vomiting  is  often 
relieved  and  the  sense  of  weight  and  fulness  diminished  by  the 
application  of  a  firm  bandage  to  the  abdomen  in  such  a  manner 
as  to  afford  support  to  the  enlarged  viscus.  Massage  and 
electricity  are  of  no  value  when  gastrectasis  arises  from  a 
growth  of  the  pylorus,  and  the  recourse  to  these  and  other 
so-called  '  cures '  is  inevitably  followed  by  much  disappoint- 
ment and  financial  loss.    It  is  possible,  however,  that  further 


252  CANCEE  OF  THE   STOMACH 

experience  may  show  that  the  Kontgen  rays  exercise  a  beneficial 
effect.  The  severe  pain  in  the  abdomen  which  ensues  from 
perigastritis  or  the  development  of  metastases  in  the  liver  and 
peritoneum  may  often  be  relieved  by  stimulant  or  sedative 
applications  to  the  skin.  In  chronic  cases  the  repeated  use  of 
small  blisters  to  the  epigastrium,  followed  by  dusting  of  the 
raw  surfaces  with  a  powder  composed  of  acetate  of  morphine 
(gr.  ^)  and  hydrochlorate  of  cocain  (gr.  £),  is  of  the  greatest 
value ;  but  in  the  more  acute  conditions  hot  fomentations  or 
poultices,  with  a  liniment  of  belladonna  or  tincture  of  opium 
sprinkled  upon  them,  are  more  beneficial. 

Lavage  may  be  employed  with  advantage  in  the  majority 
of  cases,  but  it  is  chiefly  indicated  when  obstruction  of  the 
pylorus  has  given  rise  to  dilatation  of  the  stomach.  The 
benefit  derived  from  its  use  is  of  a  threefold  kind.  In 
the  first  place,  stagnation  and  decomposition  of  the  food  are 
controlled,  the  tendency  to  secondary  gastritis  is  diminished, 
and  the  progress  of  the  dilatation  retarded.  Secondly,  the 
systematic  cleansing  of  the  surface  of  the  stomach  from  the 
thick  mucus  which  adheres  to  it  tends  to  promote  secretion 
and  to  aid  absorption  of  the  food.  Thirdly,  the  periodic 
removal  of  the  products  of  fermentation  relieves  such  symptoms 
as  acidity  and  vomiting,  and  often  stimulates  the  appetite  to  a 
remarkable  degree. 

In  order  to  obtain  the  best  results  lavage  should  be  com- 
menced as  soon  as  possible  and  performed  in  a  regular  and 
efficient  manner.  Opinions  differ  as  to  the  period  of  the 
day  when  it  should  be  employed,  and  it  is  probable  that  each 
case  requires  to  be  considered  upon  its  own  merits.  In 
most  instances  the  stomach  is  most  conveniently  washed  out 
just  before  the  patient  retires  to  bed  or  about  three  hours  after 
his  last  meal,  as  by  this  means  the  retention  of  food  during  the 
night  is  obviated  and  the  insomnia  which  so  often  arises  from 
nocturnal  indigestion  is  prevented.  As  the  disease  progresses 
a  single  lavage  is  seldom  sufficient,  and  it  is  advisable  that  the 
patient  be  taught  to  empty  and  cleanse  his  stomach  both  morn- 
ing and  evening.  For  this  purpose  warm  water  containing 
bicarbonate  of  sodium  (2-5  grains  to  the  ounce)  is  usually  all 
that  is  required  ;  but  if  an  antiseptic  is  considered  necessary, 
boracic  acid  (2  per  cent.),  salicylic  acid  (3  per  cent.),  benzoate 
of  sodium  (2  per  cent.),  resorcine  (3  per  cent.),  thymol  (05  per 


TBEATMENT  253 

cent.),  or  lysol  (01  per  cent.)  may  be  employed.  It  is  impor- 
tant to  empty  the  stomach  completely  at  the  termination  of 
the  operation,  since  the  retention  of  any  of  these  solutions  may 
give  rise  to  serious  toxic  symptoms.  A  soft  tube  is  also  of 
value  as  a  means  of  introducing  food  into  the  stomach  in  cases 
of  carcinoma  of  the  cardiac  orifice.  The  subjects  of  this  com- 
plaint should  not  be  permitted  to  exist  solely  upon  what  they 
can  manage  to  swallow,  but  from  the  onset  of  the  dysphagia 
their  nutrition  should  be  maintained  by  forcible  feeding  or 
nutrient  enemata.  The  tube  should  be  soft  and  of  moderate 
calibre,  and  be  introduced  with  the  greatest  caution.  As  soon 
as  it  has  entered  the  stomach  a  pint  and  a  half  of  peptonised 
milk,  egg  and  milk,  clear  soup,  or  other  form  of  liquid  nourish- 
ment is  poured  in  through  a  funnel  and  the  instrument  with- 
drawn. This  procedure  must  be  repeated  every  six  or  eight 
hours,  and  as  the  stricture  becomes  more  pronounced  the  size 
of  the  tube  should  be  reduced. 

The  chief  contra-indication  to  the  employment  of  a  tube  for 
lavage  or  feeding  is  the  existence  of  haemorrhage.  When  the 
vomit  constantly  contains  altered  blood,  or  attacks  of  hsemat- 
emesis  occur  at  short  intervals,  the  growth  is  invariably 
ulcerated  and  often  extensive.  In  such  cases  the  careless 
employment  of  an  instrument  may  produce  serious  results,  and 
we  have  more  than  once  seen  profuse  and  dangerous  bleeding 
ensue  after  its  use. 

Rectal  feeding  is  of  great  value  when  gastric  intolerance  is 
an  important  feature  of  the  complaint,  and  in  cases  where  it 
is  necessary  to  increase  the  nutrition  with  a  view  to  the  per- 
formance of  gastrostomy  or  gastro-enterostomy.  The  old- 
fashioned  method  of  administering  two  ounces  of  milk  every  two 
hours  should  be  abandoned  in  favour  of  much  larger  injections 
at  greater  intervals  of  time.  By  the  adoption  of  this  procedure 
the  patient  is  spared  a  great  deal  of  pain  and  inconvenience 
and  the  tendency  to  irritation  of  the  bowel  is  greatly  reduced. 
In  every  case  the  rectum  should  be  irrigated  with  normal  saline 
solution  each  morning,  and  the  enemata  be  administered  through 
a  large  soft  tube,  which  is  inserted  as  far  as  possible  into  the 
bowel.  During  the  operation  the  patient  reclines  upon  his  left 
side,  with  his  buttocks  raised  upon  a  pillow,  and  the  reservoir 
containing  the  nutrient  liquid  which  is  attached  to  the  tube  is 
suspended  about  three  feet  above  the  level  of  the  couch. 


254  CANCEE  OF  THE   STOMACH 

Atmospheric  pressure  being  the  only  force  used  in  the  ad- 
ministration of  the  enema,  the  operation  requires  three- 
quarters  of  an  hour  for  its  due  performance ;  and  if  this  time 
is  always  allowed  the  whole  quantity  is  absorbed  without  the 
least  discomfort.  As  a  rule  peptonised  milk  is  the  best  form 
of  nourishment,  and  fifteen  to  twenty  fluid  ounces  may  be 
given  in  the  manner  described  every  six  or  eight  hours.  The 
use  of  peptone  and  of  the  various  meat  essences  is  not  attended 
by  any  special  benefit,  nor  is  an  emulsion  of  meat  and  pancreas 
either  more  convenient  or  useful  than  milk.  The  majority  of 
the  so-called  nutrient  suppositories  merely  act  as  foreign  bodies 
in  the  rectum,  and  are  either  expelled  or  discovered  unaltered  in 
the  bowel  after  death.  If  a  diffusible  stimulant  is  required,  a 
tablespoonful  of  brandy  or  whisky  may  be  added  to  each 
enema.  Eggs  are  apt  to  create  an  unpleasant  odour  of  sul- 
phuretted hydrogen  in  the  sick-room. 

Diet. — Both  the  appetite  and  the  powers  of  digestion  vary 
so  much  in  different  cases  that  it  is  usually  best  to  favour,  as 
far  as  possible,  the  patient's  natural  inclinations,  and  to  abstain 
from  hard  and  fast  rules  concerning  the  diet. 

The  existence  of  severe  pain  after  meals  is  frequently  the 
sign  of  ulceration  of  the  growth,  and  should  be  treated  upon 
the  same  lines  as  in  simple  chronic  ulcer.  If  raw  milk  agrees, 
from  five  to  eight  ounces  may  be  given  every  two  hours,  but 
when  it  gives  rise  to  nausea  or  discomfort  it  should  be  pep- 
tonised, sterilised,  or  mixed  with  an  equal  quantity  of  lime- 
water.  Clear  soups,  the  Leube-Eosenthal  beef  solution,  or  the 
various  meat  essences,  jellies,  or  extracts  may  be  tried,  and  the 
diet  may  be  varied  with  eggs  beaten  up  with  milk,  poached  eggs, 
soft  bread  and  butter,  bread  and  milk,  or  milk  puddings.  In 
less  severe  cases  scraped  raw  meat,  boiled  chicken,  and  fish  that 
has  been  passed  through  a  sieve,  sweetbreads,  and  calf's  feet  or 
brains  may  be  allowed.  Green  vegetables  are  to  be  avoided, 
and  in  most  cases  raw  and  stewed  fruits  occasion  pain  or 
acidity. 

Stenosis  of  the  pylorus  accompanied  by  excessive  vomiting 
must  be  treated  with  a  dry  form  of  diet,  as  free  as  possible  from 
farinaceous  substances.  Only  the  strongest  and  most  concen- 
trated forms  of  meat  essences  or  solutions  should  be  allowed,  and 
lightly  cooked  and  finely  minced  meats,  fish,  and  eggs  should 
constitute  the  staple  food.     Tea  and  coffee  rarely  agree,   but 


TEEATMENT  255 

cocoa  made  from  the  nibs  is  often  useful.  Wines  and  malt 
liquors  are  apt  to  produce  acidity  and  vomiting,  but  a  small 
quantity  of  good  brandy  or  whisky  with  the  meals  often  aids 
digestion  and  prevents  the  fulness  and  distension  of  which  com- 
plaint is  so  frequently  made.  When  thirst  is  a  prominent 
symptom  the  patient  should  be  directed  to  sip  hot  water,  or  an 
enema  of  hot  water  may  be  administered  from  time  to  time. 
In  all  cases  nutrition  should  be  aided  by  the  administration 
of  a  large  enema  of  peptonised  milk  each  night. 

At  a  late  period  of  the  complaint  it  is  usually  necessary  to 
peptonise  the  greater  part  of  the  food,  and  to  administer  it  in 
small  quantities  at  short  intervals. 

Medicinal  Treatment. — The  search  for  a  specific  remedy 
has  produced  a  long  list  of  drugs,  each  of  which  at  one  time  or 
another  has  been  supposed  to  exercise  a  controlling  influence 
upon  the  course  of  the  disease ;  but  from  the  hard  soap 
advocated  by  Van  Swieten  to  the  infusion  of  violets  of  the 
present  day,  one  and  all  have  failed  to  check  the  progress  of  the 
morbid  growth.  It  is  therefore  necessary  to  direct  medicinal 
treatment  to  the  relief  of  the  various  symptoms  as  they  arise. 

Anorexia. — This  is  chiefly  to  be  combated  by  frequent 
changes  of  diet  and  by  the  use.  of  lavage.  In  the  early  stages 
of  the  complaint  the  various  bitters  are  occasionally  of  value ; 
but  they  seldom  agree  for  long,  and  their  injudicious  administra- 
tion is  apt  to  aggravate  the  tendency  to  gastritis.  Condurango 
is  a  favourite  remedy  with  many  practitioners,  on  account  of 
its  stomachic  properties,  and  is  best  prepared  according  to  the 
directions  of  Friedreich.  Half  an  ounce  of  the  bark  is 
macerated  for  twelve  hours  with  twelve  ounces  of  water,  after 
which  the  fluid  is  reduced  by  boiling  to  half  its  bulk  and 
strained.  One  tablespoonful  of  this  solution  combined  with 
syrup  of  orange  is  given  three  times  a  day  between  the  meals. 
Others  prefer  the  infusions  of  gentian,  calumba,  quassia,  or 
chiretta,  with  or  without  the  addition  of  nux  vomica,  while  in 
some  cases  the  cautious  administration  of  arsenic  seems  to 
improve  both  the  appetite  and  the  general  condition.  The 
fact  that  most  cases  of  carcinoma  of  the  stomach  are  attended 
by  a  diminished  secretion  of  hydrochloric  acid  naturally  suggests 
the  administration  of  this  drug  as  an  aid  to  digestion.  It  is 
chiefly  of  use  when  the  growth  affects  the  cardiac  or  central 
region  of  the  stomach  ;  but  in  pyloric  stenosis  it  often  appears 


256  CANCEE  OF  THE   STOMACH 

to  increase  the  pain  and  vomiting,  owing  to  its  irritant  influence 
upon  the  inflamed  gastric  mucosa.  Occasionally  the  use  of 
pepsin,  lactopeptine,  or  papain  seems  to  increase  the  powers  of 
digestion.  Chlorate  of  sodium  in  doses  of  sixty  grains  three 
times  a  day  was  recommended  by  Huchard,  and  is  sometimes 
of  value. 

Pain. — When  this  symptom  continues  severe  in  spite  of 
careful  dieting  and  lavage,  recourse  must  be  had  to  sedatives. 
If  it  chiefly  occurs  after  meals,  a  mixture  containing  carbonate 
of  bismuth,  bicarbonate  of  sodium,  and  dilute  hydrocyanic  acid 
will  often  diminish  its  intensity,  or  a  pill  composed  of  bella- 
donna, conium,  and  stramonium  may  be  given  immediately 
after  food.  Cocain  is  sometimes  of  use  when  the  growth  is 
situated  near  the  cardia.  At  a  later  period  opium  is  almost 
always  required.  Codeine,  nepenthe,  and  the  compound  tinc- 
ture of  chloroform  and  morphine  are  less  apt  to  disturb  the 
digestion  than  other  preparations ;  but  when  vomiting  pre- 
vents the  administration  of  drugs  by  the  mouth,  hypodermic 
injections  of  morphine  and  atropine  are  invaluable.  This 
method  is  also  the  best  fitted  to  procure  sleep. 

Vomiting. — The  treatment  of  this  symptom  varies  with  its 
cause.  When,  as  is  usually  the  case,  it  arises  from  obstruction 
of  the  pylorus,  the  daily  employment  of  lavage  combined 
with  a  dry  form  of  diet  is  at  once  the  most  appropriate  and 
successful  mode  of  treatment.  In  all  cases  the  administra- 
tion of  antiseptics  in  an  alkaline  solution  is  valuable  in  pre- 
venting excessive  fermentation  of  the  food.  For  this  purpose 
carbolic  acid  is  the  most  useful,  and  may  be  given  either  in  the 
form  of  the  glycerine  preparation  (8-12  min.)  or  the  pill. 
Occasionally  full  doses  of  resorcine,  hyposulphite  or  sulpho- 
carbolate  of  sodium,  creasote,  or  a  minim  of  the  tincture  of 
iodine  every  hour,  also  afford  relief.  During  an  attack  of 
acute  gastritis  the  irritability  of  the  stomach  prevents  the 
administration  both  of  food  and  medicine,  and  under  these 
circumstances  the  patient  should  be  confined  to  bed  and  cold 
compresses  be  applied  to  the  epigastrium,  while  the  nutrition 
is  maintained  by  rectal  feeding.  If  retching  is  an  urgent 
feature  of  the  case,  a  third  of  a  grain  of  calomel  may  be  placed 
upon  the  tongue  every  three  hours,  and  a  sixth  of  a  grain  of 
acetate  of  morphine  may  be  given  by  hypodermic  injection 
once  or    twice    a    day.     The  emesis  which  occurs  soon  after 


TEEATMEXT  257 

food,  and  is  preceded  by  violent  pain,  is  best  controlled  by 
morphine  or  nepenthe  before  meals  and  the  repeated  applica- 
tion of  a  small  blister  to  the  epigastrium.  Chloroform,  hyos- 
cyanxus,  cocaine,  and  glycerine  have  also  been  recommended 
for  this  purpose,  but  their  effects  are  variable  and  usually 
disappointing.  The  regurgitation  of  food  that  arises  from  a 
stricture  of  the  cardiac  orifice  must  be  treated  by  gavage  and 
rectal  feeding.  The  distressing  nausea  which  is  sometimes  a 
prominent  feature  of  disease  of  the  body  of  the  stomach  may 
often  be  relieved  by  the  use  of  a  mixture  containing  soda, 
hydrocyanic  acid,  and  bromide  of  potassium,  taken  half  an  hour 
before  a  meal. 

Acidity. — Acid  eructations  depend  upon  abnormal  fermen- 
tation of  the  food,  and  usually  subside  as  soon  as  the  stomach 
is  washed  out  night  and  morning.  "When  this  is  impossible, 
bicarbonate  of  sodium  with  calcined  magnesia  may  be  pre- 
scribed with  an  antiseptic,  or  a  bismuth  lozenge  may  be 
swallowed  occasionally.  Sometimes  charcoal  biscuits,  or 
powdered  charcoal  and  iodoform  enclosed  in  a  cachet,  serve  to 
alleviate  this  troublesome  symptom. 

HcBmatemesis. — Severe  haemorrhage  is  rare,  and  when  it 
occurs  must  be  treated  like  that  arising  from  simple  ulcer. 
The  patient  is  confined  to  bed  and  fed  exclusively  by  the  bowel, 
while  an  icebag  is  applied  to  the  epigastrium  in  order  to  con- 
trol the  movements  of  the  stomach.  If  necessary  a  small  dose 
of  morphine  may  be  given  by  hypodermic  injection.  The 
frequent  small  losses  of  blood  that  arise  from  general  oozing 
from  the  surface  of  the  growth  require  to  be  arrested,  on 
account  of  the  profound  anaemia  which  they  occasion.  For 
this  purpose  ergot,  hamamelis,  gallic  acid,  perchloride  of  iron, 
alum,  or  calcium  chloride  is  usually  recommended,  but  acetate 
of  lead  combined  with  extract  of  opium,  in  the  form  of  a  pill,  is 
usually  more  efficacious.  The  recent  introduction  of  the  supra- 
renal gland  has  provided  an  admirable  haemostatic  for  this  and 
other  forms  of  hgeniaternesis,  and  excellent  results  follow  the 
administration  of  the  dried  and  powdered  substance,  in  doses  of  five 
grains,  every  four  hours,  or  of  a  decoction  of  a  similar  strength. 

Boivels. — In  every  case  the  tendency  to  constipation  re- 
quires to  be  corrected  in  the  early  stages  of  the  complaint.  One 
or  two  teaspoonfuls  of  the  phosphate  or  tartrate  of  sodium 
dissolved  in  warm  water  may  be  given  each  morning  before 

s 


258  CANCEE  OF  THE   STOMACH 

breakfast,  either  by  the  mouth  or  through  the  tube  after  lavage, 
or  one  of  the  natural  aperient  waters  may  be  prescribed.  With 
the  progress  of  inanition  salines  are  apt  to  induce  exhaustion, 
and  should  be  omitted  in  favour  of  the  liquid  extract  of  cascara, 
the  syrup  or  compound  infusion  of  senna,  or  a  mild  pill  con- 
taining pcdophyllin  and  rhubarb.  Occasionally  the  daily  use 
of  a  glycerine  injection  or  suppository  is  sufficient.  Mercury 
and  drastic  purgatives  should  always  be  avoided. 

Surgical  Treatment. — (1)  Carcinoma  of  the  Pylorus. — The 
surgical  treatment  of  cancer  of  the  stomach  appears  in  a  some- 
what different  light  according  as  it  is  viewed  from  a  surgical  or 
a  medical  standpoint.  To  the  surgeon  the  chief  question  is, 
what  operation  is  likely  to  be  attended  by  the  best  results  or 
is  the  least  dangerous  under  the  circumstances.  But  to  the 
medical  attendant  the  subject  is  a  much  more  complicated  one. 
In  the  first  place,  while  confronted  by  the  fact  that  if  left 
alone  the  disease  will  inevitably  prove  fatal,  he  is  unable  to 
assure  his  patient  that  an  operation  is  devoid  of  grave  risk  or  that 
a  cure  will  result  fromlit.  Again,  he  has  to  bear  in  mind  that  the 
responsibility  of  recommending  surgical  interference,  as  well  as 
the  results  that  may  be  expected  to  accrue  from  it,  depends  almost 
entirely  upon  the  accuracy  of  his  diagnosis  ;  and  on  the  one  hand, 
if  he  waits  until  the  nature  of  the  disease  can  be  determined 
beyond  dispute,  all  hope  of  cure  by  the  knife  will  have  disap- 
peared, while  on  the  other,  if  he  maintains  that  it  exists  in 
the  absence  of  a  tumour,  it  is  possible  that  a  serious  operation 
may  be  undertaken  without  adequate  cause.  Lastly,  he  has  to 
consider  the  financial  and  domestic  concerns  of  his  patient, 
and  to  determine  whether  the  prospect  of  a  prolongation  of  life 
or  the  relief  which  may  be  afforded  to  the  symptoms  is  likely  to 
compensate  for  the  extra  danger  and  expense  incurred.  We 
believe  that  much  trouble  and  disappointment  would  be  saved  to 
both  parties  if  the  facts  were  always  explained  in  a  clear  and 
straightforward  manner  to  the  patient  and  his  friends,  to  whom 
the  decision  for  or  against  operation  could  be  safely  left. 

At  the  present  time  opinions  seem  to  be  divided  as  to  the 
best  method  of  dealing  with  a  carcinoma  of  the  pylorus,  some 
surgeons  advocating  an  attempt  to  excise  the  growth  when- 
ever it  appears  to  be  feasible,  while  others  prefer  merely  to 
relieve  the  symptoms  by  the  performance  of  gastro-enterostomy. 
Our  own  investigations  lead  us  to  believe  that,  unless  undertaken 


TEEATMENT  259 

within  the  first  two  months,  an  excision  will  seldom  be  attended 
by  a  complete  cure,  owing  to  the  rapid  infection  of  the  gastric 
and  retro-peritoneal  glands  that  occurs  in  the  majority  of  cases. 
In  this  connection  it  may  be  observed  that  a  localised  scirrhus 
which  has  undergone  colloid  degeneration  appears  to  be  the  most 
favourable  subject  for  operation,  while  a  medullary  growth  is 
the  most  rapidly  infective,  and  therefore  the  least  susceptible 
of  ablation.  Unfortunately,  statistics  are  of  little  value  as  a 
guide  either  to  the  mortality  of  pylorectomy  or  to  its  ultimate 
results,  since  the  method  of  collecting  cases  from  a  number  of 
different  sources  admits  of  no  distinction  being  made  as  to  the  age 
of  the  patient,  his  general  condition,  the  stage  of  the  disease,  or 
the  relative  skill  and  experience  of  the  operator.  In  the  series 
tabulated  by  Haberkant  the  death-rate  from  pylorectomy  was 
56-7  per  cent.,  and  in  that  by  Wolfier  31-2  per  cent. ;  while 
the  figures  of  Carle  and  Fantino  show  a  mortality  of  only  20 
per  cent.  The  same  difficulties  present  themselves  with  regard 
to  the  results  of  gastroenterostomy ;  for  while  hospital  records 
indicate  a  mortality  of  36-43-5  per  cent.,  experience  in  private 
practice  seems  to  show  that  when  the  operation  is  performed  at 
an  early  stage  of  the  disease  the  risk  to  life  is  not  greater  than 
in  cases  of  benign  stenosis  of  the  pylorus. 

Although  there  can  be  little  doubt  that  even  in  the  hands 
of  the  most  experienced  surgeons  pylorectomy  is  a  more  serious 
operation  than  gastro-enterostomy,  it  is  also  certain  that  the 
expectation  of  life  is  greater  after  a  successful  excision  than 
after  the  merely  palliative  measure.  With  the  exception  of  one 
doubtful  case  (Hahn),  we  have  been  unable  to  find  a  single 
instance  in  which  life  was  prolonged  for  more  than  two  years 
after  gastro-enterostomy  for  carcinoma.  On  the  other  hand,  in 
1896  Wolfier  was  able  to  collect  fourteen  cases  of  pylorectomy 
which  had  lived  for  more  than  two  years,  and  four  which  had 
survived  for  five  years  ;  and  since  that  date  at  least  fifteen 
others  have  been  recorded  where  life  has  been  prolonged  for 
three  years  or  more. 

Contra-indications  to  Pylorectomy . — If  the  patient  is  desirous 
of  a  radical  operation,  two  factors  require  consideration  before 
it  can  be  recommended — his  general  health  and  the  physical 
signs  of  the  disease. 

The  general  state  of  health  is  best  gauged  by  the  severity  of 
certain  symptoms. 

s  2 


260  CANCEE  OF  THE   STOMACH 

Prolonged  vomiting  is  always  attended  by  atrophy  of  the 
heart,  which  is  indicated  by  a  slow  small  pulse  of  extremely 
low  tension.  Cases  which  exhibit  this  peculiarity  are  liable  to 
die  from  heart  failure  at  any  time,  and  rarely  survive  an  opera- 
tion more  than  forty-eight  hours.  The  nutrition  may  be  esti- 
mated by  observing  the  quantity  of  sulplio  cyanide  of  potassium 
present  in  the  saliva.  A  marked  diminution  of  the  salt  is  a 
sign  of  great  enfeeblement  of  the  powers  of  digestion  and 
absorption,  while  its  absence  invariably  indicates  the  near 
approach  of  death.  Any  operation  undertaken  under  these  cir- 
cumstances will  prove  unsuccessful.  Excessive  cachexia  usually 
arises  from  ulceration  of  the  growth,  and  indicates  continued 
loss  of  blood  and  an  extensive  infection  of  the  lymphatic  system. 
Patients  who  present  this  symptom,  even  though  they  appear 
well  nourished,  are  usually  beyond  the  hope  of  cure. 

The  chief  physical  signs  which  contra-indicate  an  attempt  at 
pylorectomy  are  the  presence  of  a  palpable  tumour,  adhesions 
between  the  pylorus  and  the  liver,  and  the  existence  of  meta- 
static deposits. 

A  palpable  tumour  proves  that  the  disease  is  already  far 
advanced  and  is  accompanied  by  a  diffuse  infection.  Moreover, 
its  apparent  size  is  usually  less  than  one  half  of  its  real  dimen- 
sions, and  affords  no  clue  to  the  extent  of  the  surrounding 
infiltration  of  the  gastric  tissues.  Adhesion  of  the  tumour  to 
the  liver  is  indicated  by  its  excessive  mobility  with  respiration, 
its  resistance  to  efforts  at  lateral  displacement,  and  by  the 
impossibility  of  fixing  the  mass  at  the  lowest  point  of  its  ex- 
cursion by  pressure  of  the  hand.  Even  when  a  tumour  cannot 
be  felt,  inflation  of  the  stomach  will  usually  show  that  the 
pylorus  has  not  been  displaced  downwards  by  the  increased 
weight  of  the  organ,  but  remains  persistently  at  its  normal  level. 
The  principal  signs  of  metastases  are  to  be  found  in  the  liver, 
peritoneum,  lymphatic  glands,  and  skin.  As  a  rule,  an  increase 
in  the  area  of  hepatic  dulness  at  the  back  of  the  right  chest  can 
be  determined  before  the  edge  of  the  liver  becomes  palpable. 
The  detection  of  secondary  tumours  in  its  substance  marks  a 
very  advanced  stage  of  its  infection,  while  the  occurrence  of 
jaundice  points  to  direct  pressure  upon  the  hepatic  or  common 
bile-duct.  Peritoneal  carcinosis  shows  itself  either  hy  the 
presence  of  a  tumour  in  the  omentum  or  in  the  pouch  of 
Douglas,  or   by  the  rapid  development    of   ascites.     Enlarge- 


TEEATMENT  261 

nient  of  the  lymphatic  glands  above  the  left  clavicle,  in  the  left 
axilla,  or  in  the  right  groin,  indicates,  involvement  of  the  thoracic 
duct,  of  the  mediastina  or  the  mesentery  ;  while  retraction  of  the 
navel,  a  cord-like  band  in  the  linea  alba,  or  nodules  in  the  skin 
of  the  abdomen,  are  signs  of  an  equally  wide  diffusion  of  the 
morbid  growth. 

Indications  for  Gastroenterostomy. — The  production  of  an 
artificial  communication  between  the  stomach  and  the  small 
intestine  serves  to  allay  the  excessive  vomiting  that  ensues 
from  obstruction  of  the  pylorus,  and  in  many  cases  relieves  the 
pain  and  also  retards  the  progress  of  the  growth.  If,  therefore, 
the  vomiting  cannot  be  controlled  by  medical  treatment,  and 
threatens  to  curtail  existence  by  the  exhaustion  it  induces, 
the  operation  may  be  recommended  as  a  palliative  measure. 
To  be  accomplished  successfully  it  should  be  performed  as 
early  as  possible ;  and,  in  those  cases  which  only  come  under 
observation  in  an  advanced  state  of  exhaustion,  it  is  advisable 
to  have  recourse  to  rectal  feeding  for  several  days  before  the 
operation  is  attempted. 

(2)  Carcinoma  of  the  Cardia. — When  the  morbid  growth 
occupies  the  cardiac  end  of  the  stomach,  its  removal  is  im- 
possible, and  an  obstruction  to  the  entry  of  food  into  the  organ 
is  the  main  indication  for  surgical  interference.  In  all  cases, 
as  soon  as  the  diagnosis  of  stricture  of  the  lower  end  of  the 
oesophagus  can  be  made  gastrostomy  should  be  performed. 

(3)  Carcinoma  of  the  Body  of  the  Stomach  {Walls  and 
Curvatures. — In  these  cases  the  disease  has  already  made  such 
considerable  progress  before  an  accurate  diagnosis  can  be  made 
that  any  attempt  to  excise  the  growth  is  practically  fore- 
doomed to  failure.  Removal  of  the  entire  stomach  was  per- 
formed by  Schlatter  in  1897,  life  being  prolonged  for  fourteen 
months,  and  has  since  been  successfully  done  by  Brigham, 
MacDonald,  and  Richardson ;  but  the  operation  is  such  a  for- 
midable one  that  more  extended  experience  is  required  before 
any  opinion  as  to  its  value  can  be  expressed.  In  certain 
cases  the  excessive  pain  and  vomiting  arising  from  a  mural 
growth  can  be  relieved  by  gastro-enterostomy ;  but  as  a  rule 
the  results  are  not  more  favourable  than  those  achieved  by 
medicinal  treatment,  while  the  frequency  with  which  unex- 
pected difficulties  are  encountered  in  its  performance  does  not 
help  to  commend  the  operation. 


262  CANCEE  OP  THE   STOMACH 


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266  CANCEE  OF  THE   STOMACH 

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PAET   II 
TUMOURS   OF  THE   STOMACH  AND  DUODENUM 

CHAPTEE   I 

SARCOMA   OF  THE  STOMACH 

Although  the  occurrence  of  gastric  sarcoma  was  observed 
more  than  thirty  years  ago,  it  has  only  recently  been  recog- 
nised that  it  constitutes  an  important,  and  by  no  means 
an  infrequent,  variety  of  malignant  disease  of  the  stomach. 
This  opinion  is  founded  partly  upon  the  discovery  that  many 
specimens  which  are  described  in  museum  catalogues  as 
carcinomatous  or  fibroid  tumours  present  the  characteristic 
features  of  sarcoma  when  examined  by  the  microscope,  and 
partly  upon  the  large  number  of  cases  of  sarcoma  of  the 
stomach  that  have  been  published  since  special  attention  has 
been  directed  to  the  subject.  Thus,  Perry  and  Shaw  found 
four  instances  of  this  morbid  condition  among  fifty  specimens 
of  malignant  disease  of  the  stomach,  while  in  the  course  of 
twenty-three  consecutive  autopsies  upon  persons  who  had  died 
from  primary  neoplasms  of  the  organ  we  observed  two  examples 
of  round-cell  sarcoma.  It  may  also  be  noted  that  whereas  in 
1897  Schlesinger  was  able  to  collect  only  thirty  cases  of  the 
disease,  in  November  1900  the  number  of  recorded  instances 
exceeded  sixty,  of  which  fifty-three  at  least  may  be  regarded  as 
genuine.  Although  it  is  impossible  to  make  any  absolute 
statement  as  to  the  relative  frequency  of  the  complaint,  it  is 
probable  that  the  sarcomata  constitute  from  5  to  8  per  cent,  of 
all  primary  neoplasms  of  the  stomach.  Six  varieties  have  been 
described  up  to  the  present  time,  namely,  round-celled  sarcoma, 
spindle-celled  sarcoma,  fibro-sarcoma,  myo-sarcoma,  myxo- 
sarcoma, and  angio-sarcoma.    Of  these  the  spindle-celled  and  the 


272 


TUMOUKS   OF  THE   STOMACH 


fibro-sarcomata  are  probably  identical,  while  the  single  example 
of  myxo-sarcorna  appears  to  have  been  originally  a  case  of  the 
round-celled  type,  which  had  undergone  degeneration. 

(1)  Round-celled  Sarcoma. — This  variety  is  the  one  most 
usually  met  with,  and  was  observed  in  thirty-three  out  of  fifty- 
three  cases,  or  in  about  62  per  cent,  of  the  entire  number.  As 
a  rule,  it  occurs  in  the  form  of  a  dense  infiltration  of  the  pyloric 
third  of  the  stomach,  which  transforms  the  coats  of  this  portion 
of  the  viscus  into  a  homogeneous  yellowish- white  mass  of  rigid 
consistence  and  considerable  thickness.  The  peritoneal  aspect 
is  often  covered  with  lymph,  while  the  inner  surface  is  slightly 


Fig.  54. —  Section  of  a  stomach  showing  round-cell  infiltration  of 
the  submucosa  (sarcoma).     (  x  100.) 

uneven,  or  even  distinctly  nodular,  and  is  occasionally  super- 
ficially ulcerated.  If  the  pylorus  is  greatly  thickened,  its  orifice 
may  be  partially  stenosed,  as  in  cases  of  spheroidal-celled  car- 
cinoma ;  but  as  a  rule  the  rigidity  of  its  tissues  renders  it  patent 
and  the  valve  incompetent  rather  than  contracted.  The  growth 
gradually  shades  off  towards  the  centre  of  the  organ,  but  it  is 
often  prolonged  for  some  distance  along  the  curvatures  in  the 
form  of  thick  striae  or  bands.  In  almost  every  instance, 
whether  the  pylorus  is  stenosed  or  not,  the  cardia  is  dilated  and 
its  mucous  membrane  shows  signs  of  chronic  inflammation. 
In  about  one-sixth  of  the  cases  the  entire  organ  was  infiltrated 


SARCOMA   OF  THE   STOMACH 


273 


by  the  growth,  which  also  tended  to  invade  the  lower  end  of 
the  oesophagus  and  the  first  portion  of  the  duodenum.  The 
walls  of  the  stomach  were  greatly  thickened  and  its  cavity 
contracted,  while  in  some  instances  the  inner  surface  presented 
extensive  superficial  ulceration.     In  only  two   cases  out  of  the 


Fig.  55. — A  spindle-celled  sarcoma,  the  size  of  a  small  potato,  attached  to 
the  fundus  of  the  stomach  and  the  gastro-splenic  omentum.  (London 
Hospital  Museum.) 


entire  number  did  the  disease  occur  as  a  circumscribed  tumour 
in  the  wall  of  the  viscus,  with  secondary  nodules  in  the  sur- 
rounding mucous  membrane. 

(2)    Spindle-cell   or   Fibro-sarcoma. — This   variety   comes 
next  in  order  of  frequency,  and  constituted  twelve  out  of  the 

T 


274  TUMOUES  OF  THE   STOMACH 

fifty-three  cases,  or  22  per  cent.  It  usually  presents  itself  as  a 
round  or  oval  circumscribed  tumour  of  the  wall  of  the  stomach 
in  the  neighbourhood  of  the  great  curvature.  As  it  grows  it 
tends  to  project  more  and  more  beneath  the  serous  coat,  and 
exerts  such  traction  upon  its  point  of  origin  that  it  not  only  drags 
the  whole  organ  downwards,  but  often  acquires  a  pedunculated 
appearance.  These  tumours  sometimes  attain  an  enormous  size 
(121b.,  Cantwell),  and  may  fill  the  greater  part  of  the  abdominal 
cavity.  "When  small  they  are  smooth  and  firm  on  section,  but  as 
their  bulk  increases  they  become  knotty  and  irregular  in  shape, 
and  their  tissue  often  undergoes  cystic  degeneration.  These 
changes  are  seldom  accompanied  by  extensive  adhesions,  but 
occasionally  give  rise  to  perforation  of  the  stomach  (Ewald). 

(3)  The  Myo-sareomata  are  much  rarer  than  either  of  the 
preceding,  only  five  examples  having  been  recorded  up  to  the 
present  time.  They  form  smooth  or  slightly  nodular  tumours 
in  the  gastric  wall  near  the  great  curvature,  and  frequently 
show  signs  of  cystic  degeneration.  Like  the  fibro-sarcomata, 
they  may  grow  to  an  enormous  size,  Brodowski  having  met  with 
one  which  weighed  twelve  pounds. 

(4)  Angiosarcoma  has  been  twice  recorded  (Bruch  and 
Kosinski).  In  one  case  it  formed  a  tumour  as  large  as  an 
infant's  head,  with  many  cysts,  due  to  interstitial  haemorrhages, 
scattered  through  its  substance. 

Metastases. — Each  variety  is  apt  to  give  rise  to  secondary 
growths  in  organs  more  or  less  remote  from  the  primary  disease  ; 
but  the  round-cell  is  by  far  the  most  malignant  type,  for  out  of 
twenty-three  cases  of  the  latter  in  which  full  details  are  given, 
sixteen,  or  70  per  cent.,  exhibited  metastases.  In  almost  every 
instance  the  lymphatic  glands  immediately  connected  with  the 
stomach  were  enlarged,  and  in  nearly  50  per  cent,  were 
sarcomatous  ;  while  in  a  few  cases  the  retro-peritoneal,  mesen- 
teric, and  even  the  mediastinal,  cervical,  and  supra-clavicular 
glands  were  affected.  One  or  both  kidneys  presented  secondary 
deposits  in  28  per  cent. ;  the  liver,  ovaries,  pancreas,  adrenals, 
and  omentum  each  in  14  per  cent. ;  and  the  lungs,  diaphragm, 
pleurse,  oesophagus,  intestine,  and  mesentery  in  about  7  per 
cent,  of  the  cases.  It  is  also  important  to  notice  that  nodules 
of  growth  were  present  in  the  skin  of  the  abdomen,  thorax,  or 
back  in  about  12  per  cent,  of  the  entire  number. 

The  spindle-cell  variety  was  accompanied  by  metastases  in 


SARCOMA   OF  THE   STOMACH 


275 


the  perigastric  glands  in  37  per  cent,  of  the  cases,  and  in  the 
skin,  liver,  and  diaphragm  in  12  per  cent,  of  the  cases.  In  two 
out  of  the  five  cases  of  niyo-sarcoma  secondary  growths  were 
found  in  the  liver. 

Other  Points  of  Distinction  from  Carcinoma. — Owing  to  the 
infrequent  infection  of  the  peritoneum  there  is  usually  a  notable 
absence  of  the  elongated  and  nodular  epigastric  tumour  which 
is  so  often  present  in  cancer-         y- — 

ous  disease  of   the    stomach     ^"  ^  ._^«r-, 

from  infiltration  and  adhesion 
of  the  great  omentum.  Again, 
in  about  15  per  cent,  of  the 
cases  of  round-cell  sarcoma 
the  spleen  is  so  much  en- 
larged as  to  project  below  the 
costal  margin.  This  increase 
of  size  is  due  not  to  the  ex- 
istence of  a  morbid  growth 
in  its  substance,  but  to  con- 
gestion and  hyperplasia  of 
the  splenic  pulp,  a  condition 
which  rarely  occurs  in  carci- 
noma (see  p.  74).  Kundrat 
has  observed  enlargement  of 
the  tonsils,  with  occasional 
swelling  and  ulceration  of  the 
follicles  of  the  tongue,  and 
lays  considerable  stress  upon 
their  diagnostic  significance ; 
but  these  phenomena  are 
confined    to    the    round-cell 

variety  and  are  of  rare  occurrence.  Perforation  of  the 
stomach,  followed  by  general  peritonitis,  takes  place  in  about 
11  per  cent.,  and  is,  consequently,  more  frequent  than  in 
carcinoma,  owing  probably  to  the  greater  tendency  to  softening 
of  the  growth  and  to  the  absence  of  protective  adhesions.  On 
the  other  hand,  a  perigastric  abscess  from  this  cause  has  not 
hitherto  been  observed.  Death  from  haemorrhage  has  only 
once  been  recorded  (Robert),  and  in  one  instance  the  disease 
gave  rise  to  a  gastro-colic  fistula.  True  carcinoma  was  twice 
found  associated  with  round-cell  sarcoma. 

T    2 


Fig. 


56. —  Secondary  growth  of 
melanotic  sarcoma. 


276  TUMOURS   OF  THE   STOMACH 

r 

Secondary  Sarcomata  of  the  stomach  are  more  common 
than  secondary  carcinomata,  and  are  usually  of  the  round-cell 
variety.  They  have  been  observed  as  the  result  of  disease  of  the 
retro-peritoneal  glands  (Maier,  Perry),  ca3cum  (Beck),  neck, 
pharynx,  gums  (Kundrat),  rectum,  and  superior  maxilla  ;  also  in 
cases  of  general  sarcomatosis  (Malmsten,  Carry). 

"When  sarcoma  spreads  into  the  stomach  by  contiguity 
the  pyloric  region  is  often  affected  by  a  uniform  infiltration, 
but  when  the  original  growth  is  remotely  situated  the  meta- 
stases usually  appear  as  rounded  tumours  or  thick  wheals 
situated  in  the  submucous  tissue.  These  deposits  often  soften 
and  ulcerate,  and  may  even  undergo  partial  cicatrisation. 

Etiology. — The  round-cell  sarcoma  appears  to  affect  both 
sexes  with  equal  frequency,  and  to  develop  at  any  age  from  the 
first  to  the  eighth  decade.  There  is,  however,  a  distinct 
tendency  for  it  to  appear  at  an  earlier  period  than  carcinoma, 
since  the  mean  age  in  twenty-nine  cases  was  only  thirty-four 
years.  The  fibro-sarcomata,  on  the  other  hand,  have  been  met 
with  far  more  frequently  in  women  than  in  men  (nearly  5:1), 
the  average  age  at  the  time  of  death  being  fiftj^-one  years. 
The  only  exception  to  this  rule  recorded  up  to  the  present  time 
is  the  case  of  Finlayson's,  where  a  male  child  died  from  a 
fibro-sarcoma  of  the  stomach  at  the  age  of  three  and  a  half. 
In  two  instances  where  the  solid  tumour  was  a  myo-sarcoma 
the  patients  were  males  about  fifty  years  of  age. 

Round-cell  sarcoma,  like  carcinoma,  is  prone  to  follow  a 
local  injury  and  to  develop  in  the  scar  of  an  old  wound.  In  a 
case  related  by  Brooks  a  soft  growth  originated  in  the  cicatrix 
of  a  former  bullet-wound  of  the  lesser  curvature,  and  in  one 
which  came  under  the  authors'  observation  a  large  secondary 
melanotic  tumour  was  found  in  the  base  of  a  simple  chronic  ulcer. 

Symptoms. — The  general  symptoms  of  sarcoma  of  the 
stomach  are  essentially  the  same  as  those  that  accompany 
carcinoma  of  the  organ  (p.  106).  One  of  the  earliest  and 
most  striking  features  of  the  complaint  is  progressive  loss  of 
flesh  with  failure  of  physical  power.  This  is  most  conspicuous 
in  young  persons  and  in  those  cases  where  a  round-cell: 
growth  has  given  rise  to  contraction  of  the  pyloric  orifice. 
When  the  neoplasm  affects  only  a  comparatively  small  area  of 
the  stomach,  as  in  the  spindle-cell  and  myo-sarcomata,  emacia- 
tion is  chiefly  observed  in  the  later  stages  of  the  complaint  or 


SAECOMA  OF  THE   STOMACH  277 

after  ulceration  has  occurred.  Anaemia  is  always  present  and 
gradually  increases  ;  but  if  there  is  continued  fever  or  repeated 
haemorrhages  occur  the  pallor  develops  rapidly,  and  may  rival 
that  met  with  in  pernicious  anaemia.  It  is  characterised  by  a 
great  diminution  both  of  haemoglobin  and  red  corpuscles,  and 
in  one  of  the  recorded  cases  the  colouring  matter  amounted  to 
only  15  per  cent,  of  the  normal  a  few  days  before  death.  Occa- 
sionally a  slight  degree  of  leucocytosis  may  be  observed,  but 
the  increase  of  white  corpuscles  which  normally  occurs  after 
meals  (Digestion-leucocytosis)  is  usually  absent.  As  a  rule  the 
appetite  fails,  especially  in  the  round-cell  growth,  from  the  first, 
and  there  may  be  a  special  distaste  for  meat ;  but  sometimes  the 
desire  for  food  continues  unimpaired  throughout  (Easch,  Baldy), 
or  anorexia  manifests  itself  only  during  the  last  few  weeks  of 
life  (Maass,  Fleiner).  Thirst  varies  with  the  severity  of  the 
anaemia  and  vomiting.  Pyrexia  is  by  no  means  uncommon  in 
young  persons  and  in  those  cases  in  which  the  neoplasm  grows 
rapidly  or  undergoes  degenerative  changes ;  it  may  therefore  be 
present  throughout  the  whole  course  of  a  round-cell  sarcoma  or 
in  the  later  stages  of  the  other  varieties.  This  febrile  reaction  is 
usually  continuous,  but  is  seldom  severe  (99-102°  F.),  and  often 
gives  place  to  an  abnormally  low  temperature  for  some  days 
before  death.  Irregular  attacks  of  pyrexia  also  accompany  the 
development  of  perigastritis,  pneumonia,  pylephlebitis,  and  the 
formation  of  secondary  growths  in  the  lungs.  Albuminuria 
occurs  in  about  one-sixth  of  all  cases,  and  is  especially  frequent 
in  the  round-cell  sarcomata.  It  is  usually  associated  with 
metastases  in  the  kidneys.  If  vomiting  is  a  prominent  feature 
of  the  case,  the  bowels  may  be  confined,  but  in  the  round- 
cell  variety  diarrhoea  is  more  often  encountered  than  consti- 
pation. 

Local  symptoms  are  present  in  almost  every  instance  of 
round-cell  sarcoma  of  the  stomach,  but  in  those  varieties 
which  are  accompanied  by  the  formation  of  a  localised  slow- 
growing  tumour  the  ordinary  phenomena  indicative  of  gastric 
disease  may  be  entirely  wanting.  In  the  case  related  by  Baldy 
the  appetite  continued  good  and  there  was  no  complaint  either 
of  pain  or  sickness,  although  the  entire  stomach  was  involved 
in  an  enormous  tumour;  while  in  another  instance  (Cantwell), 
where  the  growth  weighed  twelve  pounds,  the  digestive 
functions  remained  unimpaired   until   the   end.      Bobert  has 


278  TUMOUES   OF  THE   STOMACH 

also  recorded  one  in  which  the  first  and  only  indication  of  an 
extensive  growth  was  an  attack  of  hsematemesis. 

In  about  76  per  cent,  of  all  cases  abdominal  pain  is 
experienced  during  some  period  of  the  disease.  It  varies 
greatly,  however,  in  its  character  and  severity.  As  a  rule,  it 
does  not  amount  to  more  than  a  sense  of  fulness  and  oppression 
after  meals,  such  as  commonly  ensues  from  gaseous  distension 
of  the  stomach ;  but  in  about  15  per  cent,  of  the  recorded  cases 
it  was  described  as  having  been  severe  and  increased  shortly 
after  meals.  It  is  interesting  to  observe  that  in  most  of  these 
either  the  growth  was  ulcerated  or  there  was  considerable 
invasion  of  the  pancreas  or  retro-peritoneal  glands.  Constant 
and  severe  suffering  is  usually  indicative  of  perigastritis  or 
secondary  infection  of  the  liver.  The  solid  tumours  (fibro-  and 
myo-sarcomata),  unless  ulcerated  internally,  are  more  often 
accompanied  by  sensations  of  weight  and  dragging  than  by 
actual  pain. 

Vomiting  is  usually  a  later  symptom,  unless  the  pylorus  is 
contracted.  At  first  it  occurs  at  intervals,  but  as  the  stomach 
becomes  dilated  it  is  repeated  more  frequently,  and  the  ejecta 
are  found  to  present  the  usual  features  which  characterise 
stagnation  and  decomposition  of  the  food.  Vomiting  occur- 
ring soon  after  meals  and  preceded  by  pain  usually  indicates 
ulceration  of  the  growth,  while  the  attacks  of  incessant  retch- 
ing, attended  by  the  expulsion  of  mucus,  which  are  apt  to 
appear  from  time  to  time,  and  are  often  so  severe  as  to  preclude 
the  administration  of  food,  result  from  secondary  inflammation 
of  the  mucous  membrane.  In  the  case  of  the  large  solid 
tumours,  vomiting  is  a  less  frequent  phenomenon  (48  per  cent.), 
and  seldom  appears  until  after  the  lapse  of  from  five  to 
seven  months.  Fsecal  vomiting  is  usually  an  indication  of  a 
gastro-colic  fistula. 

Haemorrhage  from  the  stomach  is  seldom  a  prominent 
symptom  of  round-cell  sarcoma,  owing  to  the  comparative 
infrequency  of  ulceration  of  the  growth.  It  is  probable, 
however,  that  capillary  oozing  is  of  constant  occurrence,  since 
the  gastric  contents  removed  by  a  tube  are  often  found  to  be 
mixed  with  coffee-ground  material ;  while  careful  examination 
of  the  stools  may  demonstrate  the  existence  of  altered  blood 
(Schlesinger).  In  the  spindle-cell  variety  of  the  disease  repeated 
attacks  of  hsematemesis  wTere  observed  in  nearly  half  the  cases, 


SAECOMA  OF  THE   STOMACH  279 

and  in  two  instances  a  severe  hemorrhage  was  the  first  symptom 
to  attract  attention. 

Physical  Signs. — A  palpable  tumour  connected  with  the 
stomach  is  an  inconstant  sign  of  round-cell  sarcoma,  and  was 
observed  in  only  about  30  per  cent,  of  the  recorded  cases.  In 
most  instances  it  is  produced  by  a  local  thickening  of  the 
gastric  wall  in  the  region  of  the  pylorus,  and  was  described  as 
a  round  or  oval  mass,  occupying  the  right  hypochondriac  or 
epigastric  region,  smooth  on  the  surface,  somewhat  tender  on 
pressure,  and  often  freely  movable.  Rapid  increase  in  size 
can  sometimes  be  observed.  In  other  instances  the  tumour 
consists  of  the  entire  stomach,  and  more  than  once  the  con- 
comitant enlargement  of  the  spleen  has  been  mistaken  for  a 
malignant  mass.  In  the  fibro-  and  myo-sarcomata  a  tumour 
is  almost  always  present,  and  is  often  so  large  as  to  occupy  the 
greater  part  of  the  abdominal  cavity.  If  the  growth  is  situated 
near  the  great  curvature,  it  is  usually  detected  in  the  umbilical, 
left  hypochondriac,  or  lumbar  region,  where  it  forms  a  smooth, 
firm,  painless  mass  which  is  dull  on  percussion  and  freely 
movable  in  all  directions.  This  latter  peculiarity  affords  a 
marked  contrast  to  the  behaviour  of  a  carcinomatous  growth 
in  the  same  position,  which  soon  becomes  fixed  by  extensive 
adhesions  to  the  neighbouring  viscera.  In  two  cases  where  the 
tumour  was  attached  to  the  posterior  wall  of  the  stomach  it  filled 
the  lesser  sac  of  the  peritoneum,  and  was  consequently  covered 
by  the  stomach  and  transverse  colon,  although  being  some- 
what pedunculated  it  could  easily  be  moved  from  side  to  side. 

Dilatation  of  the  stomach  can  be  detected  in  every  case  of 
sarcoma  of  the  pylorus,  and  when  the  orifice  is  contracted  the 
peristaltic  movements  of  the  enlarged  viscus  are  usually  visible. 
When  the  organ  is  affected  by  diffuse  infiltration  its  cavity 
is  contracted  and  its  outlines  are  obscured  by  the  transverse 
colon. 

Metastatic  deposits  in  the  skin  constitute  an  important 
feature  of  the  disease.  As  a  rule  they  appear  in  the  form  of 
one  or  two  small  nodules  in  or  around  the  umbilicus ;  but 
occasionally  they  are  very  numerous  and  are  scattered  all  over 
the  abdomen,  chest,  and  back.  They  vary  in  size  from  a  millet- 
seed  to  a  small  bean,  and  at  first  are  freely  movable  in  the 
subcutaneous  tissue,  but  after  a  time  they  become  adherent  to 
the  skin  and  may  even  give  rise  to  ulceration.     Enlargement 


280  TUMOUES   OF  THE   STOMACH 

of  the  supra-clavicular  and  cervical  glands  is  rarely  observed, 
while  sarcomatous  infiltration  of  the  tongue  is  still  less  com- 
mon. In  one  case  a  correct  diagnosis  was  made  by  the  dis- 
covery of  a  secondary  growth  in  the  rectum.  Generalisation 
of  the  disease  is  occasionally  accompanied  by  the  symptoms  of 
purpura  (Eedtenbacher). 

Chemical  examination  of  the  contents  of  the  stomach 
affords  similar  results  to  those  met  with  in  gastric  cancer. 
Free  hydrochloric  acid  disappears  at  an  early  stage  of  the  com- 
plaint (Fleiner,  Schlesinger),and  fermentation  of  the  food  often 
produces  an  excess  of  lactic  acid  (Dreyer,  Maass,  Hammerslag). 
Sarcinse  may  or  may  not  be  present,  and  Schlesinger  has  been 
able  to  demonstrate  the  presence  of  the  Oppler-Boas  bacillus, 
which  was  supposed  to  occur  only  in  cases  of  cancer.  The 
sulphocyanide  of  potassium  in  the  saliva  gradually  diminishes 
as  the  disease  progresses,  and  finally  disappears  about  one 
month  before  death. 

Duration  and  Complications. — It  is  difficult  to  estimate 
the  exact  duration  of  a  disease  which  commences  so  insidiously 
and  is  often  unaccompanied  by  definite  physical  signs  for  many 
months.  It  would  appear,  however,  from  a  study  of  the 
recorded  cases,  that  although  the  round-cell  sarcomata  often 
run  their  course  in  three  or  four  months,  the  average  duration 
of  the  disease  is  about  fifteen  months ;  while  in  the  case  of  the 
spindle-cell  and  myo-sarcomata  life  is  prolonged  on  the  average 
for  two  years  and  eight  months.  It  will  be  observed  that  in 
both  instances  the  duration  of  the  disease  is  greater  than  that 
of  cancer,  a  result  which  probably  depends  upon  its  lesser 
malignancy  and  its  lesser  liability  to  produce  ulceration  of  the 
mucous  membrane  and  stenosis  of  the  pylorus.  Death  usually 
occurs  from  exhaustion,  and  is  often  preceded  by  a  semi- 
comatose state  lasting  for  several  days.  Perforation  of  the 
stomach,  followed  by  general  peritonitis,  occurs  in  10  per  cent, 
to  12  per  cent,  of  the  cases  of  round-cell  sarcoma,  and  may 
even  take  place  in  the  spindle-cell  form  (Ewald),  but  owing 
to  the  absence  of  adhesions  a  perigastric  abscess  is  excep- 
tional. Fatal  hemorrhage  is  very  rare.  In  two  instances 
general  sarcomatosis  tended  to  shorten  the  period  of  life,  while 
in  one  an  attack  of  tetany  similar  to  that  met  with  in  cicatricial 
stenosis  of  the  pylorus  was  immediately  responsible  for  the 
fatal   termination    (Fleiner).      Excessive  ascites,  albuminuria, 


SAECOMA   OF  THE   STOMACH  281 

portal  thrombosis,  and  pneumonia   all  accelerate  the  natural 
course  of  the  disease. 

Diagnosis. — So  far  as  the  recognition  of  the  malignant 
nature  of  the  disease  is  concerned,  the  sarcomata  do  not  offer 
any  particular  difficulty.  The  intractable  character  of  the 
gastric  symptoms,  coupled  with  the  progressive  emaciation, 
physical  debility,  and  cachexia,  indicates  a  profound  disturbance 
of  the  processes  of  digestion  and  assimilation,  while  the  dis- 
covery of  a  growing  tumour  connected  with  the  stomach,  or  of 
metastases  in  other  viscera,  demonstrates  at  once  the  existence 
of  a  neoplasm.  A  more  interesting  question  is  the  clinical 
differentiation  of  sarcoma  from  carcinoma.  A  diagnosis  of 
round-cell  sarcoma  of  the  stomach  may  often  be  made  by 
attention  to  the  following  facts :  (1)  The  disease  usually 
occurs  before  thirty-five  years  of  age,  so  that  the  younger  the 
patient,  the  greater  the  probability  that  the  malignant  affection 
is  sarcomatous  in  character.  (2)  In  many  cases  there  is  slight 
but  continuous  pyrexia,  accompanied  by  rapid  and  profound 
anaemia,  while  in  carcinoma  fever  is  usually  absent  during  the 
early  stages  of  the  complaint  and  the  cachexia  much  more 
gradual  in  its  development.  (3)  Enlargement  of  the  spleen 
is  by  no  means  infrequent,  but  is  rarely  met  with  in  cancer 
unless  the  organ  is  involved  in  the  growth.  (4)  According 
to  Kundrat,  the  tonsils  are  apt  to  enlarge  and  the  follicles 
upon  the  sides  of  the  tongue  may  become  swollen  or  ulcerated. 
(5)  Secondary  deposits  in  the  skin  occur  in  a  notable  propor- 
tion of  the  cases,  and  permit  of  excision  and  microscopical 
examination.  It  should  be  remembered,  however,  that  sarco- 
matosis  has  been  met  with  in  true  cancer  of  the  stomach 
(Leube).  (6)  A  large  nodular  tumour  due  to  infiltration  of  the 
omentum,  and  a  greatly  enlarged  liver  with  secondary  growths 
in  its  substance,  are  rarely  met  with.  (7)  Persistent  albumin- 
uria is  often  observed  in  sarcoma  but  is  exceptional  in  cancer. 
(8)  The  discovery  of  pieces  of  morbid  growth  in  the  vomit 
renders  the  diagnosis  certain  (Kiegel,  Westphalen). 

The  spindle-cell  and  myo- sarcomata  are  chiefly  charac- 
terised by  their  comparatively  slow  growth,  a  smooth,  firm, 
and  movable  tumour,  the  frequent  absence  of  pain,  vomiting, 
and  anorexia,  and  by  the  tendency  to  repeated  haemorrhage. 

When  the  tumour  occupies  the  lesser  sac  of  the  peritoneum 
it  may  be  mistaken  for  a  cyst  of  the  pancreas.     It   should  be 


282  TOIOUES   OF   THE   STOMACH 

noticed,  however,  that  in  the  latter  disease  pain  after  food, 
vomiting,  and  hsematernesis  are  usually  absent,  while  the 
tumour  itself  is  firmly  fixed,  is  smooth,  elastic  to  the  touch, 
and  tends  to  come  forward  between  the  lower  border  of  the 
stomach  and  the  colon.  In  every  case  of  doubt  an  explora- 
tory operation  should  be  undertaken. 

Treatment. — The  medicinal  treatment  is  the  same  as  that 
of  gastric  cancer.  The  diet  must  be  carefully  regulated  and 
the  food  peptonised  if  necessary.  Symptoms  of  fermentation 
may  be  allayed  by  the  administration  of  antiseptics  and  the 
employment  of  lavage,  while  severe  pain  requires  the  exhibition 
of  morphine  and  other  sedatives. 

Many  of  the  recorded  cases  have  been  subjected  to  surgical 
treatment,  with  considerable  success  so  far  as  the  immediate 
objects  of  the  operation  were  concerned.  Torok,  Dock,  Schopf, 
and  others  have  removed  considerable  portions  of  the  stomach 
affected  by  the  round-cell  growth,  and  in  at  least  one  case 
(Schopf)  there  was  no  recurrence  at  the  end  of  a  year.  The 
solid  tumours  are  especially  favourable  for  extirpation,  as  they 
are  often  pedunculated  and  involve  a  comparatively  small  area 
of  the  gastric  wall.  Hartley  removed  a  large  fibro-sarcoma 
and  Kosinski  a  cystic  angio-sarcoma  with  apparent  success ; 
while  in  Cantwell's  case  the  excision  of  a  spindle-cell  sarcoma 
weighing  twelve  pounds  gave  great  relief  to  the  patient  for  eight 
months.  If  one  may  judge  from  the  morbid  anatomy  of  the 
disease,  the  surgical  treatment  of  sarcomata  of  the  stomach  will 
prove  far  more  successful  than  can  ever  be  expected  in  carcinoma, 
but  it  is  too  early  as  yet  to  determine  the  prospects  of  a  per- 
manent cure. 

BIBLIOGRAPHY 

Baldy,  Journal  of  the  American  Medical  Association,  1898,  vol.  i.  p.  523. 

Brodowski,  Virchow's  Archiv,  vol.  lxvii. 

Brooks,  Medical  News,  1898,  p.  617. 

Briich,  Diagnose  der  bosartigen  Gesehwiilste,  Mainz,  1847. 

Cantwell,  Annals  of  Surgery,  1899,  vol.  ii.  p.  596. 

Gayley,  Transactions  of  the  Pathological  Society  of  London,  1869,  vol.  xx. 

Cliernjaeff,  Ejened  Klin.  Gaz.,  St.  Petersburg,  1886,  vol.  vi.  p.  665. 

Dock,  Journal  of  the  American  Medical  Association,  vol.  xxxv.  p.  156. 

Dreyer,  Ueber  das  Magensarcom.      Inaugural  Dissertation,  Gottingen  1894. 

Drost,  TJeber  primare  Sarcomatose  des  Magens.  Inaugural  Dissertation,  Miinchen 

1894. 
Ewald,  Klinik  der  Verdauungskrankheiten,  Theil  ii.  p.  354. 
Fenwick,  Saltan,  Lancet,  1901,  i.  p.  463. 


SAECOMA  OF  THE   STOMACH  283 

Finlayson,  Brit.  Med.  Journ.,  1899,  vol.  ii.  p.  1535. 

Fleiner,  Lehrbuch  der  Krankheiten  der  Verdauungsorgane,  Theil  i.  p.  295. 

Hodden,  Transactions  of  the  Pathological  Society  of  London,  1885,  vol.  xxxvii. 

p.  234. 
Hammerslag,  Archiv   fur   Verdauungskrankheiten,    Theil   ii.   Heft   1,   Beobach- 

tung  10. 
Handford,  Transactions   of   the  Pathological   Society   of  London,  1888,  vol.  xl. 

p.  89. 
Hardy,  Gazette  des  Hopitaux,  1878,  p.  25. 
Hartley,  Annals  of  Surgery,  1896,  vol.  xxiii.  p.  609. 
Kehr,  Langenbeck's  Archiv.  lviii.  3. 
A'osi»sA;i,  Bericht  viber  die  Verhandlungen  der  deutschen  Gesellschaft  fur  Chirurgie, 

1892. 
Kundrat,  Wiener  klinische  Wochenschrift,  1893,  p.  12. 
Legg,  Transactions  of  the  Pathological  Society  of  London,  vol.  xxv.  p.  121. 
Lowe,  Brit.  Med.  Journ.,  1886,  vol.  ii.  p.  1033. 
Maass,  Deutsche  rnedicinische  Wochenschrift,  1895,  p.  34. 
Maier,  Archiv  Mr  Heilkunde,  1871,  Heft  2. 
Mintz,  Berliner  klinische  Wochenschrift,  1900,  xxxii.  p.  708. 
Perry,  Glasgow  Medical  Journal,  1883,  p.  215. 
Perry  &  Shaw,  Guy's  Hospital  Beports,  1892,  p.  48. 
Rasch,  Hospitaltidende,  1894,  p.  849. 

Redtenbacher,  Jahrbuch  der  Wiener  Krankenanstalten,  1894,  p.  560. 
Riegel,  Die  Erkrankungen  des  Magens,  ii.  p.  874. 
Robert,  Allgemeine  rnedicinische  Central-Zeitung,  1894,  p.  1153. 
Scliepelern,  Hospitaltidende,  B.  ii.  1,  p.  35. 
Sclilesinger,  Zeitschrift  fin*  klinische  Mediein,  1897,  p.  179. 
Schopf,  Centralblatt  fur  Chirurgie,  1899,  p.  1163. 
Toroh,  Centralblatt  fur  Chirurgie,  1892,  p.  99. 
Virchow,  Die  krankhaften  Geschwiilste,  2. 
Weissbhim,  Ueber  primare  und  secundare  Magensarcom.     Inaugural  Dissertation 

Greifswald  1886. 
Westphalen,  Petersburger  rnedicinische  Wochenschrift,  1893,  xlv.  p.  403. 


281  TUMOUBS   OF  THE   STOMACH 


CHAPTEE    II 

CARCINOMA   AND   SARCOMA    OF  THE  DUODENUM 

Caecinoma  affects  the  duodenum  as  a  primary  disease  much  less 
frequently  than  the  stomach.  In  the  course  of  42,000  post- 
mortem examinations  made  in  Vienna,  a  primary  malignant 
growth  was  found  in  the  intestines  in  443  cases,  but  in  only 
seven,  or  0"017  per  cent.,  was  the  duodenum  the  seat  of  the 
disease  (Schlesinger).  According  to  Perry  and  Shaw,  ten 
examples  of  the  complaint  occurred  in  18,000  necropsies 
performed  at  Guy's  Hospital  (0-05  per  cent.),  but  of  these  only 
four  are  stated  to  have  been  carcinomatous  ;  while  among  19,518 
post-mortems  recorded  at  the  London  Hospital,  we  find  that  the 
duodenum  was  the  seat  of  a  cancerous  growth  in  eighteen,  or 
in  about  0-09  per  cent.  If  allowance  be  made  for  the  occasional 
inclusion  of  sarcomata  in  the  latter  statistics,  it  would  appear 
that  primary  carcinoma  of  the  duodenum  is  met  with  once  in 
about  1,500  to  2,000  necropsies  in  London,  and  thus  presents 
a  ratio  to  gastric  cancer  of  1  to  20.  According  to  the  statistics 
of  Maydl  and  Schlesinger,  the  duodenum  is  affected  in  about 
2  per  cent,  of  the  cases  of  primary  malignant  disease  of  the 
intestine. 

The  great  majority  of  duodenal  cancers  belong  to  the 
cylinder-celled  variety,  but  spheroidal-celled  growths  are  not 
uncommon,  and  Atkinson  states  that  colloid  cancer  is  relatively 
frequent.  Adeno-carcinoma  usually  encircles  the  gut,  and 
gives  rise  to  a  contraction  of  its  lumen  which,  viewed  from  the 
outside,  looks  as  though  a  piece  of  string  had  been  tied  tightly 
round  the  bowel.  Less  commonly  the  growth  infiltrates  the 
walls  for  some  distance  above  the  stricture,  and  gives  the 
diseased  tissues  a  funnel-shaped  appearance.  The  spheroidal 
carcinomata  either  take  the  form  of  soft  flat  excrescences,  or 
of  deep  ulcers  with  elevated  irregular  edges  and  fungating 
bases. 


CAECINOMA  AND   SAECOMA  OF  THE  DUODENUM     285 

The  disease  may  occur  at  any  part  of  the  duodenum,  but  is 
most  frequent  in  the  second  or  vertical  portion,  where  its  seat 
of  election  is  the  mucous  membrane  covering  the  biliary  papilla. 
Out  of  fifty-one  cases  which  we  have  collected,  the  first  part 
was  affected  in  eleven,  or  21-5  per  cent.,  the  second  in  twenty- 
nine,  or  57  per  cent.,  and  the  third  in  seven,  or  13-5  per  cent., 


Fig.  57.— Primary  carcinoma  of  the  first  part  of  the  duodenum,  involving 
the  pylorus.     (London  Hospital  Museum.) 

while  in  the  remaining  8  per  cent,  the  disease  involved  the 
whole  or  greater  portion  of  the  duodenum. 

Secondary  Carcinoma  is  usually  the  result  of  an  extension 
of  the  disease  from  a  neighbouring  organ.  In  the  majority  of 
the  cases  the  head  of  the  pancreas  is  the  seat  of  the  primary 
mischief,  but  in  not  a  few  of  these  it  probably  commenced  in 
the  lining  membrane  of  the  ampulla  of  Yater.     In  others  the 


286  TUMOUES   OP  THE   STOMACH 

duodenum  is  involved  by  a  growth  of  the  gall-bladder,  of  the 
bile-duct,  of  Wirsung's  duct  of  the  pancreas,  of  the  omentum, 
of  the  retro-peritoneal  glands,  or  of  the  right  adrenal.  The  first 
part  is  also  apt  to  be  invaded  by  a  growth  of  the  pylorus 
(p.  58). 

Multiple  Carcinomata  are  occasionally  encountered,  but  they 
almost  always  arise  either  by  contact  infection  or  by  transplanta- 
tion of  particles  detached  from  a  growth  higher  up.  In  rare 
instances  cancer  of  the  duodenum  is  associated  with  cancer  of 
the  stomach  or  of  the  oesophagus  (Lannois  and  Courmont). 

Primary  Sarcoma  of  the  duodenum  is  very  rare,  and  only 
about  twenty-cases  have  been  recorded.  As  a  rule  the  disease 
is  of  the  round-cell  variety,  and  involves  all  three  portions 
of  the  bowel,  while  not  infrequently  the  jejunum  and  ileum  are 
also  affected.  The  wall  of  the  gut  is  greatly  thickened,  but 
its  lumen  is  more  often  increased  than  diminished  (Libman). 
The  growth  may  compress  the  biliary  and  pancreatic  ducts 
(Lancereaux),  or  it  may  give  rise  to  extensive  ulceration  and 
lead  to  fatal  haemorrhage  (Eolleston). 

Secondary  Sarcomata  chiefly  occur  in  cases  of  melanosis  or 
of  lympho-sarcoma  of  the  retro-peritoneal  glands. 

Etiology. — Like  simple  ulcer  in  the  same  situation,  carci- 
noma is  more  frequent  in  men  than  in  women,  no  fewer 
than  thirty-seven  out  of  our  fifty-one  cases  having  been  of 
the  male  sex.  The  average  age  at  the  time  of  death  was 
fifty-three  years,  the  mean  duration  of  life  in  the  male  cases 
being  fifty-two  years,  and  in  the  female  fifty-four  years. 
Nattan-Larrier,  however,  found  that  in  rather  more  than  one 
third  of  the  cases  he  collected  the  patient  was  over  seventy 
years  of  age.  The  disease  is  apt  to  follow  a  chronic  ulcer,  at 
least  ten  instances  in  which  this  sequence  of  events  occurred 
having  been  placed  on  record  (Perry  and  Shaw,  Nattan-Larrier, 
Letulle).  In  other  cases,  and  more  especially  in  women,  the 
carcinoma  is  associated  with  the  presence  of  gall-stones. 

Symptomatology. — The  symptoms  of  duodenal  cancer  vary 
according  to  the  situation  of  the  growth.  When  the  first  or 
horizontal  portion  of  the  bowel  is  affected  the  patient  presents 
all  the  indications  of  pyloric  stenosis,  and  a  differential  dia- 
gnosis is  extremely  difficult.  Disease  of  the  second  or  vertical 
part  is  apt  to  involve  the  orifice  of  the  common  bile-duct,  so 
that  its  location  may  often  be  determined  during  life  by  the 


CAECINOMA  AND   SAECOMA  OF  THE   DUODENUM     287 

coexistence  of  jaundice  and  enlargement  of  the  liver ;  while  a 
stricture  of  the  duodenum  below  the  biliary  papilla  is  usually- 
attended  by  bilious  vomiting  and  the  presence  of  pancreatic 
juice  in  the  ejecta.  It  is  therefore  convenient  to  consider  the 
clinical  aspect  of  the  disease,  according  as  it  is  situated  above, 
around,  or  below  the  biliary  papilla. 

(1)  Carcinoma  above  the  Biliary  Papilla  (Supm-ampullary 
or  Parapyloric  Cancer). — In  this  position  the  growth  may 
either  form  a  ring  round  the  bowel,  just  below  the  pylorus,  or 
produce  a  deep  ulcer  with  overhanging  edges,  the  base  of 
which  is  adherent  to  the  liver  or  pancreas.  In  both  cases  the 
lumen  of  the  intestine  is  considerably  diminished,  though 
never  entirely  obstructed.  The  complaint  is  chiefly  encountered 
in  men  of  middle  age,  and  sometimes  follows  simple  ulcera- 
tion. 

The  initial  symptoms  are  somewhat  indefinite,  and  princi- 
pally consist  of  discomfort  and  flatulence  after  meals,  acidity, 
loss  of  appetite,  and  general  debility.  There  is  also  slight  but 
progressive  loss  of  flesh,  with  marked  pallor  of  the.  mucous 
membranes.  After  a  month  or  two  pyrosis  makes  its  appear- 
ance, and  is  followed  within  a  short  time  by  vomiting.  At  first 
the  emesis  may  occur  only  about  once  a  week,  and  is  followed 
by  an  amelioration  of  the  other  symptoms ;  but  it  gradually  be- 
comes more  and  more  frequent,  until  finally  it  takes  place  once 
or  twice  every  twenty-four  hours.  The  vomit  consists  of  an 
acid  sour-smelling  liquid,  mixed  with  masses  of  undigested  food. 
Free  hydrochloric  acid  is  usually  absent,  but  lactic  acid  may 
be  present  in  excess.  It  is  generally  stated  that  the  ejecta  are 
free  from  bile,  but  as  a  matter  of  fact  a  severe  attack  of  retch- 
ing is  not  infrequently  accompanied  by  the  rejection  of  a  green 
bilious  fluid  which  has  regurgitated  through  the  incomplete 
stricture.  At  this  period  severe  pain  may  be  experienced  in 
the  epigastrium  or  right  hypochondrium  shortly  after  meals,  and 
is  almost  always  an  indication  that  the  growth  has  undergone 
superficial  ulceration.  Ha3matemesis  is  less  frequent  than  in 
cancer  of  the  stomach,  but  traces  of  altered  blood  may  some- 
times be  observed  in  the  stools,  and  occasionally  there  is  severe 
melsena.  In  the  early  stages  of  the  complaint  the  bowels  are 
confined,  but  subsequently  diarrhoea  may  supervene  and  prove 
difficult  to  control.  Bile  is  usually  present  in  the  stools,  and, 
according  to  Charon  and  Ledegank,  colloid  material  may  often 


288  TUMOUES   OF  THE   STOMACH 

be  recognised  in  the  evacuations  when  the  disease  has  under- 
gone that  form  of  degeneration. 

On  examination  the  stomach  is  found  to  be  greatly  dilated, 
and  its  contractions  are  often  visible  through  the  abdominal 
wall.  In  about  60  per  cent,  of  the  cases  in  which  the  disease 
is  situated  close  to  the  pylorus  a  tumour  may  be  detected  upon 
palpation,  and  is  sometimes  large  enough  to  be  evident  upon 
inspection.  It  is  usually  oval  or  globular  in  shape,  smooth  on 
the  surface,  dull  on  percussion,  painful,  and  slightly  movable ; 
but  if  it  is  adherent  to  the  liver  or  pancreas  its  outlines  are 
less  definite,  and  the  presence  of  the  colon  in  front  of  it  may 
endow  it  with  a  resonant  note. 

The  subsequent  course  of  the  disease  is  similar  to  that  of 
pyloric  cancer.  Ascites  may  occur  from  carcinoma  of  the  peri- 
toneum or  pressure  upon  the  portal  vein,  while  jaundice  may 
result  from  secondary  growths  in  the  liver  or  from  an  extension 
to  the  biliary  papilla.  Perforation  into  the  general  cavity  of 
the  peritoneum  is  a  rare  event,  but  a  slight  leakage  not  infre- 
quently gives  rise  to  a  localised  abscess,  which  burrows  upwards 
to  the  diaphragm  or  points  near  the  umbilicus. 

(2)  Carcinoma  in  the  Vicinity  of  the  Biliary  Papilla 
(Cancer  of  the  Second  Portion  of  the  Duodenum  Or  Periam- 
pullary) . — In  the  second  part  of  the  duodenum  the  growth  may 
commence  either  in  the  mucous  membrane  covering  the 
papilla,  or  at  some  spot  in  its  vicinity.  In  the  former  case  the 
first  indication  is  usually  jaundice,  while  in  the  latter  the  signs 
of  pyloric  or  intestinal  obstruction  precede  those  which  arise 
from  occlusion  of  the  bile-duct. 

Carcinoma  of  the  papilla  is  usually  of  the  cylinder-celled 
type,  and  takes  the  form  of  a  soft  growth,  which  subsequently 
ulcerates.  As  a  rule,  a  yellow  tinge  of  the  skin  and  con- 
junctivae is  the  first  symptom  to  attract  attention,  and  it  may  be 
several  weeks  before  pain  or  vomiting  develops.  In  other 
cases  the  icterus  occurs  quite  suddenly  after  an  attack  of  sick- 
ness, or  its  onset  may  be  heralded  by  repeated  chills  and  inter- 
mittent pyrexia.  It  is  worthy  of  notice  that  the  colouration  of 
the  skin  is  seldom  very  intense,  and  that  the  bronzed  or  olive 
tint  that  accompanies  malignant  disease  of  the  bile-duct  is 
rarely  observed,  while  not  infrequently  the  jaundice  alternately 
deepens  and  fades,  or  appears  to  be  favourably  affected  by 
saline  aperients.     When  ulceration  occurs,  the  growth  which 


CAECINOMA   AND   SAECOMA   OP  THE  DUODENUM     289 


obstructed  the  orifice  of  the  duct  may  be  quite  destroyed,  and 
the  bile  may  once  more  find  a  free  exit  into  the  bowel.  Under 
these  conditions  the  icterus  either  disappears  completely  or  the 
urine  alone  continues  to  give  indication  of  the  presence  of  bile 
in  the  circulation. 

The  course  of  the  disease  depends  upon  the  extent  of  the 
growth  and  the  development  of  complications.  As  a  rule,  the 
jaundice  continues  with  varying  intensity,  and  the  patient 
steadily  loses  flesh  and  strength.  The  appetite  is  often  better 
preserved  than  in  gastric  cancer,  but  there  is  usually  great 
distaste  for  fats,  and  sometimes  excessive  thirst.  The  tongue 
is  foul,  pain  and  flatulence  are  experienced  two  or  three  hours 
after  every  meal,  and  constant  nausea  or  eructation  of  sul- 
phuretted hydrogen  is  a  frequent  source  of  complaint.  Vomit- 
ing is  seldom  absent,  and  at  this  stage  of  the  disease  usually 
occurs  once  or  twice  a  day.  The  ejecta  are  copious  in  quantity, 
and  consist  of  a  brownish  sour-smelling  fluid,  which  deposits 
a  thick  sediment  of  undigested  food,  and  is  usually  devoid  of 
free  hydrochloric  acid.  Notwithstanding  the  presence  of 
jaundice  and  the  absence  of  bile  from  the  stools,  the  vomit 
occasionally  exhibits  a  bright  green  colour.  Hsematemesis  is 
comparatively  rare,  but  altered 
blood  is  not  infrequently  ob- 
served in  the  evacuations. 

On  examination,  the  epi- 
gastrium is  found  to  be  slightly 
distended,  and  there  may  be 
some  degree  of  rigidity  of  the 
right  rectus  muscle.  The  liver 
is  invariably  enlarged,  and  its 
lower  border  extends  for  an  inch 
or  more  below  the  costal  margin. 
Careful  palpation  will  also  reveal 
the  presence  of  a  distended  gall- 
bladder, in  the  form  of  an 
elongated  elastic  tumour,  which 
is  attached  to  the  under  surface 
of  the  liver  and  is  capable  of 
slight  lateral  displacement.  At  first  it  is  situated  near  a 
vertical  line  drawn  from  the  tip  of  the  ninth  rib,  but  as  the 
liver  enlarges  it  may  be  pushed  several  inches  to  the  right.     A 

u 


Fig.  58. — Diagram  illustrating  the 
physical  signs  of  dilatation  of  the 
stomach  and  first  part  of  the 
duodenum,  with  enlargement  of  the 
liver  and  gall-bladder. 


290  TUMOUES   OF  THE   STOMACH 

tumour  due  to  the  intestinal  growth  can  seldom  be  detected, 
but  if  the  pancreas,  retro -peritoneal  glands,  or  the  omentum 
are  invaded,  a  hard  nodular  and  painful  mass  may  be  felt 
in  the  region  of  the  navel.  Dilatation  of  the  stomach  is 
always  present,  and  in  many  cases  the  contractions  of  its 
hypertrophied  walls  are  visible  through  the  abdominal  parietes. 
Although  death  usually  ensues  from  inanition  at  the  end  of  six 
to  eight  months,  it  may  occur  at  a  much  earlier  period  from 
biliary  toxaemia  or  other  complications. 

Case  XXII.  A  woman,  aged  fifty-four,  was  admitted  into  the 
London  Temperance  Hospital  in  a  comatose  condition,  with  deep  jaun- 
dice. Her  husband  stated  that  about  nine  weeks  previously  she  had 
been  seized  with  pain  and  sickness  after  eating  some  pickled  pork,  and 
on  the  next  day  had  become  yellow.  The  appetite  had  been  bad,  and 
she  had  complained  of  feeling  weak,  but  had  not  lost  flesh  to  any 
appreciable  extent.  Two  days  before  admission  into  the  hospital  she 
had  become  drowsy  and  had  vomited  several  times.  The  patient 
was  a  stout  well-developed  woman.  The  skin  was  bright  yellow, 
and  the  urine  contained  a  large  quantity  of  bile,  but  no  albumin  or 
sugar.  There  was  profound  coma  with  laboured  respiration,  a  slow 
feeble  pulse,  and  dilated  pupils.  The  liver  extended  nearly  three 
inches  below  the  margin  of  the  ribs,  and  presented  a  sharp  edge  and 
smooth  surface.  The  gall-bladder  formed  a  well-defined  tumour  to 
the  right  of  the  mammary  line.  The  stomach  appeared  to  be  normal 
in  size,  and  no  abdominal  tumour  could  be  detected.  The  gastric 
contents,  extracted  by  a  tube,  contained  a  trace  of  free  hydrochloric 
acid.     Death  took  place  in  a  few  hours. 

Necropsy.  The  liver  was  much  enlarged,  and  its  tissue  deeply 
bile-stained.  The  gall-bladder  contained  eight  ounces  of  green  bile, 
and  the  cystic,  hepatic,  and  common  bile-ducts  were  greatly  dilated. 
When  the  duodenum  was  opened,  an  ulcer  the  size  of  a  shilling, 
having  a  hard  irregular  edge  and  fungating  base,  was  found  to 
occupy  the  position  of  the  biliary  papilla.  Vater's  ampulla  was 
dilated,  and  its  opening  on  the  floor  of  the  ulcer  was  obscured  by  a 
small  fungoid  growth.  There  were  no  secondary  deposits  in  the  liver, 
but  three  lymphatic  glands  behind  the  peritoneum  were  enlarged. 
The  duodenal  growth  proved  to  be  a  cylindrical-celled  carcinoma. 

Occasionally  the  patient  is  attacked  by  a  succession  of 
rigors,  accompanied  by  irregular  pyrexia  and  delirium.  Severe 
pain  is  experienced  in  the  right  hypochondrium  and  epigas- 
trium, and  vomiting  is  urgent.  Rapid  enlargement  of  the  liver 
takes  place,  the   jaundice   deepens,  and  death  usually  occurs 


CAECINOMA  AND   SAECOMA  OF  THE   DUODENUM     291 

within  a  week.  In  a  case  of  this  kind  which  recently  came  under 
our  care,  carcinoma  of  the  head  of  the  pancreas  with  portal 
pyaemia  was  diagnosed,  but  the  necropsy  showed  a  small 
cancerous  growth  of  the  biliary  papilla,  with  purulent  infiltra- 
tion of  the  hepatic  and  pancreatic  ducts. 

In  rare  instances  suppurative  cholecystitis  results  from  a 
pyaemic  infection  of  the  bile-duct,  and  may  terminate  by  per- 
foration of  the  gall-bladder,  as  in  the  following  case  recorded  by 
Cockle  :  — 

Case  XXIII.  A  coal  porter,  aged  fifty-three,  was  admitted  into 
hospital  on  February  5,  1883,  for  slight  jaundice.  He  had  enjoyed 
fairly  good  health  until  Christmas,  when  he  caught  cold.  Since  then 
he  had  had  slight  rigors  and  had  lost  flesh  and  strength,  but  had  not 
complained  of  pain.  On  admission  the  patient  was  emaciated  and 
slightly  jaundiced.  The  margin  of  the  liver  extended  about  one  inch 
below  the  ribs  in  the  nipple  line.  There  was  neither  pain,  oedema  of 
the  legs,  nor  ascites  ;  the  faeces  were  pale. 

February  15. — Eigors ;  temperature,  101-2°  ;  pulse,  100. 

February  17. — Jaundice  more  intense  ;  liver  dulness  extended  three 
and  a  half  inches  below  the  costal  margin.  From  the  lower  border  of 
the  liver,  and  continuous  with  it,  there  seemed  on  palpation  to  be  an 
enlargement  of  firm  consistence,  which  extended  to  within  two  inches 
of  the  iliac  crest  and  yielded  a  resonant  note  on  percussion,  being 
apparently  overlapped  by  the  distended  colon.  Swelling  not  tender. 
Patient  very  drowsy  and  thirsty.     Temperature,  103-2°, 

February  19. — Jaundice  increased  ;  swelling  larger  ;  liver  dulness 
reached  iliac  crest ;  no  pain,  but  tenderness  on  palpation  over  the 
liver. 

February  20. — The  localised  swelling  had  increased  in  size,  and 
fluctuation  could  be  detected.  Slight  oedema  of  the  abdominal  wall ; 
patient  weak  and  torpid,  with  hectic  flush  on  cheeks ;  pulse,  100 ; 
temperature,  102-7°. 

February  21. — Patient  suddenly  became  worse ;  acute  pain  in  the 
abdomen,  which  was  distended  and  tympanitic.  Died  on  the  following 
day. 

Necropsy.  The  peritoneal  cavity  contained  several  pints  of  sero- 
bilious  fluid  and  about  a  quarter  of  a  pint  of  pus,  which  escaped  from 
a  perforation  in  the  gall-bladder.  The  intestines  were  coated  with 
recent  lymph  and  the  coils  glued  together.  The  gall-bladder  was  enor- 
mously dilated,  and  measured  when  empty  eight  inches  in  length  and 
four  and  a  half  inches  in  width.  On  its  under  surface  was  an  opening  the 
size  of  a  sixpence,  with  thickened  and  ragged  edges.  The  common  bile, 
cystic,  and  hepatic  ducts  were  all  dilated.  On  opening  the  duodenum 
a  soft  growth  was  found,  entirely  surrounding  the  orifice  of  the  bile- 

v  2 


292  TUMOUES    OP  THE   STOMACH 

duct  and  invading  the  intestine  for  three  inches  in  its  long  axis,  and 
involving  half  its  circumference.  Above  the  growth  the  bowel  was 
much  dilated.  The  lymphatic  glands  in  the  neighbourhood  were 
enlarged,  but  there  were  no  metastases  in  the  liver. 

When  the  carcinoma  only  invades  the  biliary  papilla  during 
the  course  of  its  growth  the  clinical  picture  it  presents  is 
somewhat  different  from  the  preceding.  Should  the  disease  have 
commenced  high  up,  the  initial  symptoms  are  those  of  pyloric 
obstruction.  Pain  or  discomfort  is  experienced  two  or  three 
hours  after  food,  and  there  are  usually  flatulence,  acidity,  and 
vomiting,  with  signs  of  hypertrophy  and  dilatation  of  the 
stomach.  The  vomit  is  devoid  of  free  hydrochloric  acid,  and 
occasionally  it  presents  a  green  colour,  owing  to  regurgitation 
of  bile  through  the  partially  obstructed  bowel.  Hsematemesis 
and  nielsena  may  occur  from  ulceration  of  the  growth,  and  may 
even  prove  fatal.  Should  the  disease  undergo  colloid  degenera- 
tion, small  semi-transparent  granules  of  colloid  material  some- 
times appear  in  the  faeces. 

If  the  growth  develops  below  the  level  of  the  papilla,  the 
first  symptoms  are  those  of  obstruction  of  the  bowel,  with 
constant  vomiting  of  bilious  fluid  containing  trypsin.  In  either 
case  its  extension  to  the  orifice  of  the  bile-duct  is  followed  by 
jaundice,  with  enlargement  of  the  liver  and  gall-bladder.  It 
should  be  noticed,  however,  that  even  when  this  complication 
ensues  a  certain  amount  of  bile  may  still  appear  in  the  vomit 
or  faeces,  while  in  some  cases  the  only  indications. of  biliary 
obstruction  consist  of  the  presence  of  bile  in  the  urine  and 
distension  of  the  gall-bladder. 

(3)  Carcinoma  below  the  Biliary  Papilla  {Cancer  of  the 
Third  Portion  of  the  Duodenum,  Infra-ampullary  or  Juxta- 
jejunal). — This  usually  occurs  in  the  form  of  an  annular  growth, 
which  produces  a  considerable  degree  of  stenosis.  Both  the 
stomach  and  the  duodenum  above  the  disease  are  much  enlarged, 
and  the  pyloric  orifice  is  dilated.  As  in  the  preceding  varieties, 
the  first  symptoms  consist  of  flatulence  and  discomfort  after 
meals,  acidity,  loss  of  appetite,  and  gradual  emaciation.  After  the 
lapse  of  a  few  months  vomiting  appears,  and  persists  until  the 
end.  The  tongue  now  becomes  thickly  coated,  the  thirst 
excessive,  and  there  is  marked  cachexia  and  rapid  loss  of  flesh. 
The  bowels  are  obstinately  confined,  but  the  stools  are  seldom 
quite  devoid  of  bile,  and  occasionally  contain  altered  blood. 


CAKCINOMA   AND   SAECOMA  OF  THE  DUODENUM     293 

The  character  of  the  vomit  constitutes  one  of  the  most 
important  features  of  the  disease.  It  always  contains  bile, 
which  gives  it  a  bright  green  colour,  and  if  the  patient  is 
restricted  to  a  semi-solid  diet,  the  ejecta  may  closely  resemble 
chopped  spinach.  The  liquid  obtained  by  filtration  is  neutral 
or  slightly  alkaline  in  reaction,  and  if  warmed  to  the  tempera- 
ture of  the  body  is  usually  capable  of  digesting  fibrin,  owing 
to  the  fact  that  it  contains  pancreatic  juice.  The  sediment  that 
remains  upon  the  filter  consists  of  undigested  food  in  a  state  of 
fine  subdivision,  and  is  quite  unlike  the  bulky  masses  which  are 
vomited  in  cases  of  pyloric  stenosis.  From  time  to  time  attacks 
of  intestinal  obstruction  supervene,  attended  by  incessant  vomit- 
ing and  obstinate  constipation.  On  these  occasions  from  ten 
to  fifteen  pints  of  an  alkaline  bilious  fluid  may  be  vomited  in 
the  course  of  twenty-four  hours,  notwithstanding  the  fact  that 
the  patient  has  taken  nothing  by  the  mouth.  The  urine  is 
greatly  reduced  in  amount,  and  may  even  be  suppressed, 
while  that  which  is  voided  is  alkaline  in  reaction  and  opaque 
from  an  excess  of  earthy  phosphates.  When  boiled  with  nitric 
acid,  it  sometimes  assumes  a  dark  red  or  port-wine  colour, 
owing  to  the  presence  of  a  colourless  chromogen,  allied  to  indol 
and  indican,  which  has  been  produced  by  decomposition  in  the 
dilated  bowel.  A  similar  reaction  is  sometimes  obtained  in 
cases  of  melanosis,  owing  to  the  existence  of  melanogen  in  the 
urine ;  but  in  this  instance  the  addition  of  perchloride  of  iron 
produces  a  brown  colouration — a  reaction  which  is  absent  in 
cases  of  duodenal  cancer.  In  rare  instances  the  chromogen  is 
changed  to  indican  in  the  body,  and  the  urine  has  a  distinct 
blue  colour  when  voided.  Eolleston  noted  an  excess  of  creatinin 
in  the  case  which  he  recorded.  Symptoms  of  auto -intoxication 
are  often  present  at  this  stage  of  the  complaint,  and  consist  of 
urgent  dyspnoea,  restlessness,  palpitation,  thirst,  and  delirium. 
Intense  itching  of  the  skin,  like  that  met  with  in  biliary  and 
renal  toxaemias,  is  sometimes  observed,  and  urticarial  eruptions 
occasionally  follow  the  acute  attacks  of  duodenal  obstruction. 
Examination  of  the  abdomen  shows  the  stomach  to  be  much 
enlarged,  and  a  succussion  splash  may  be  obtained  as  far  out- 
wards as  the  right  mammary  line,  or  even  in  the  lumbar  region. 
This  latter  phenomenon  is  apt  to  be  ascribed  to  dilatation  of 
the  pyloric  region  of  the  stomach,  but  is  really  due  to  the 
duodenum,   which,  being  greatly  enlarged  above  the  stricture, 


294  TUMOUES  OP  THE   STOMACH 

forms  a  distended  sac  behind  and  to  the  right  of  the  pylorus. 
When  the  disease  merely  forms  a  narrow  ring  round  the  bowel, 
no  tumour  can  be  detected  by  palpation,  but  if  the  growth  is 
accompanied  by  enlargement  of  the  retro-peritoneal  glands,  or 
has  infiltrated  the  pancreas,  an  ill- defined  hard  mass  may  be 
felt  to  the  right  of  the  umbilicus.  Exploration  of  the  stomach 
with  a  soft  tube  elicits  three  facts  of  considerable  importance. 
In  the  first  place,  it  may  be  observed  that  after  the  organ  has 
been  apparently  emptied  a  fresh  gush  of  fluid  occurs  when 
the  patient  coughs  or  inclines  his  body  to  the  left  side,  a 
phenomenon  which  is  obviously  due  to  regurgitation  of  the 
contents  of  the  duodenum  through  the  incompetent  pylorus. 
Secondly,  after  the  stomach  has  been  evacuated  a  succussion 
splash  may  still  be  obtained  over  a  limited  area  to  the  right  of 
the  navel,  owing  to  the  presence  of  fluid  in  the  duodenum. 
Finally,  after  the  stomach  has  been  washed  out  overnight,  and 
no  food  taken  in  the  meanwhile,  a  quantity  of  bilious  fluid  may 
be  extracted  in  the  morning.  These  three  phenomena,  taken 
in  conjunction  with  the  physical  signs  aforementioned,  render 
the  diagnosis  of  stricture  of  the  third  part  of  the  duodenum 
almost  a  matter  of  certainty. 

Case  XXIV.  A  carpenter,  aged  fifty-six,  was  admitted  into  the 
London  Temperance  Hospital  with  the  following  history.  He  had 
always  been  in  good  health  until  five  months  previously,  when  he 
was  suddenly  seized  with  a  bilious  attack,  and  vomited  for  two  days. 
Since  that  time  he  had  suffered  from  flatulence  and  discomfort  after 
meals,  loss  of  appetite,  and  steady  emaciation.  Latterly  he  had 
vomited  once  or  twice  each  day,  and  had  become  very  weak.  The 
bowels  were  confined,  and  micturition  was  accompanied  by  a  scalding 
pain  in  the  penis.  On  examination  the  patient  was  found  to  be  very 
thin  and  anaemic,  with  a  purple  flush  on  either  cheek,  which  was 
stated  to  have  developed  during  the  course  of  his  illness.  The  pulse 
was  small  and  compressible,  the  tongue  covered  with  a  creamy  fur, 
the  breath  offensive,  and  the  temperature  sub-normal.  The  bowels 
were  confined,  but  the  stools  contained  bile.  The  lower  border  of  the 
stomach  extended  nearly  one  inch  below  the  level  of  the  navel,  and 
its  pyloric  portion  appeared  considerably  dilated,  since  a  succussion 
splash  could  be  obtained  as  far  outwards  as  the  right  anterior  axillary 
line.  The  organ  could  be  seen  to  contract  slowly  from  left  to  right. 
The  liver  was  enlarged,  and  the  lower  edge  projected  one  inch  below 
the  costal  margin  (fig.  59).  There  was  neither  ascites  nor  jaundice, 
nor  could  any  localised  tenderness  or  tumour  be  detected   in   the 


CAKCINOMA  AND   SAKCOMA   OF   THE  DUODENUM    295 


abdomen.  The  thoracic  viscera  were  normal.  The  vomit  during  the 
first  night  in  the  hospital  amounted  to  eighteen  ounces,  and  consisted 
of  an  alkaline  opaque  fluid  of  a  deep  green  colour,  which  deposited  a 
flocculent  precipitate  on  standing.  Gmelin's  test  gave  a  positive 
reaction,  and  after  the  addition  of  a  few  grains  of  bicarbonate  of 
sodium  the  filtrate  digested  fibrin.  The  urine  was  much  reduced  in 
amount,  and  contained  a  trace  of  albumin.  After  the  stomach  had 
been  washed  out  overnight,  and  no  food  taken  in  the  interval,  thirteen 
ounces  of  bilious  fluid  were  extracted  by  a  tube  on  the  following 
morning,  and  even  after  the  organ  had  been  apparently  emptied 
a  splash  could  still  be  obtained  to  the  right  of  the  umbilicus.  Daily 
lavage,  combined  with  careful  dieting,  afforded  considerable  relief  for 
the  first  ten  days,  but  the  loss  of  weight  still  continued.  At  the  end  of 
a  fortnight  it  was  noted  that  the  patient  was  not  so  well.     Vomiting 


Fig.  59 — Physical  signs 
in  Case  XXIV. 


Fig.  60. 


-Post-mortem  appearances 
in  Case  XXIV. 


occurred  each  night  despite  the  lavage,  and  the  right  lobe  of  the 
liver  had  increased  in  size  and  presented  a  small  superficial  nodule. 
Attacks  of  extreme  restlessness  alternated  with  periods  of  somnolence, 
and  at  night-time  he  suffered  from  fits  of  choking,  accompanied  by 
urgent  dyspnoea.  On  the  eighteenth  day  after  admission  the  bowels 
ceased  to  act  and  incessant  vomiting  set  in,  which  lasted  for  three 
days  and  precluded  the  administration  of  nourishment  by  the  mouth. 
During  this  period  from  six  to  nine  pints  of  a  thin  alkaline  green  fluid 
were  ejected  every  twenty-four  hours.  The  urine  was  scanty,  and 
assumed  a  dark  red  tint  when  boiled  with  nitric  acid.  A  week  later 
fluid  was  detected  in  the  peritoneal  cavity,  and  the  patient  complained 
of  great  distension  after  meals.  A  gland  above  the  left  clavicle  was 
also  found  to  be  enlarged,  and  the  nodule  in  the  right  lobe  of  the 
liver  was  more  distinct.      A  few  days  afterwards   the  temperature 


296  TUMOUKS  OP  THE   STOMACH 

suddenly  rose  to  101°  F.,  and  he  became  delirious.  There  was  no 
cough  or  expectoration,  and  the  respirations  were  only  twenty-four  per 
minute.  The  following  day  the  temperature  had  fallen  to  99°,  but 
the  patient  was  semi-unconscious,  with  a  dry  tongue  and  a  pulse-rate 
of  136.  Comparative  dulness  on  percussion  was  detected  at  the  base 
of  the  right  lung,  and  a  few  moist  crepitations  were  audible  on 
auscultation.  During  the  evening  the  temperature  rose  to  102°,  the 
coma  deepened,  and  death  occurred  in  the  early  morning. 

Necropsy. — The  anterior  portion  of  the  abdominal  cavity  was 
chiefly  occupied  by  two  thin-walled  sacs,  which  lay  side  by  side. 
The  one  on  the  left  consisted  of  a  dilated  stomach,  while  the  other, 
which  was  ovoid  in  shape  and  eight  inches  in  length,  with  a  maximum 
circumference  of  thirteen  inches,  represented  the  upper  two  thirds  of  the 
duodenum  in  a  state  of  extreme  distension  (fig.  60).  When  the  latter 
was  laid  open,  its  lower  end  was  found  to  be  the  seat  of  an  ulcerated 
malignant  growth,  which  had  so  contracted  the  lumen  of  the  bowel 
that  it  hardly  admitted  the  tip  of  the  index  finger.  The  retro-peritoneal 
glands  were  much  enlarged,  and  the  liver  contained  four  secondary 
growths.  There  was  recent  pneumonia  in  the  lower  lobe  of  the  right 
lung.     The  growth  was  a  columnar-celled  carcinoma. 

Cases  have  been  recorded  in  which  the  whole  or  greater 
part  of  the  duodenum  was  infiltrated  with  carcinoma,  and 
converted  into  a  thick  rigid  tube  of  small  diameter.  The 
symptoms  that  accompany  this  rare  form  of  disease  are  essen- 
tially those  of  chronic  intestinal  obstruction,  accompanied  by 
excessive  vomiting  and  dilatation  of  the  stomach.  Jaundice  is 
an  inconstant  phenomenon,  but  melsena  is  not  infrequent.  In 
Arrachard's  case  a  large  membranous  cast  was  evacuated  after 
the  administration  of  an  aperient,  and  death  was  preceded  by 
troublesome  diarrhoea. 

Duration  and  Complications. — In  our  series  of  cases  the 
average  duration  of  the  complaint  was  about  seven  months,  the 
extreme  limits  being  three  and  eighteen  months.  As  a  rule 
the  fatal  event  is  due  to  exhaustion  from  inanition,  but  when 
it  occurs  at  an  early  period  it  may  take  place  from  auto- 
intoxication or  some  other  complication.  Fatal  haemorrhage 
has  been  recorded  only  twice,  and  perforation,  with  genera} 
peritonitis,  is  rare.  An  intra-peritoneal  abscess  is  rather  more 
common  than  in  simple  ulcer,  and  usually  points  at  the 
umbilicus  or  makes  its  way  towards  the  upper  surface  of  the 
liver.  Suppuration  behind  the  peritoneum  is  very  exceptional. 
Occasionally   the    growth    pi  educes    an    external    fistula,    or 


CAECINOMA  AND   SAECOMA   OF  THE  DUODENUM-    297 

establishes  a  communication  with  the  transverse  colon  or  with 
the  gall-bladder.  In  the  case  recorded  by  Trevelyan  death 
occurred  from  tetany. 

Diagnosis. — Primary  malignant  disease  of  the  duodenum  is 
accompanied  by  two  varieties  of  symptoms,  one  of  which  is 
common  to  all  cases,  while  the  other  varies  with  the  situation 
of  the  growth.  The  former  comprises  progressive  emaciation, 
cachexia,  loss  of  appetite,  vomiting,  hsemateniesis  or  melsena, 
constipation  alternating  with  diarrhoea  and  pain  in  the  abdomen 
after  meals,  with  the  signs  of  dilatation  of  the  stomach,  and 
perhaps  a  palpable  tumour.  The  latter,  or  localising  symptoms, 
on  the  other  hand,  consist  of  jaundice  with  enlargement  of  the 
liver  and  distension  of  the  gall-bladder,  attacks  of  intestinal  ob- 
struction, vomiting  of  bile  and  pancreatic  juice,  the  presence  of 
a  chromogen  in  the  urine,  and  the  signs  of  dilatation  of  the 
stomach  and  duodenum. 

Disease  of  the  first  part  of  the  duodenum  has  to  be  distin- 
guished from  benign  and  malignant  strictures  of  the  pylorus, 
and  from  the  effects  of  pressure  exerted  upon  the  bowel  by  an 
external  tumour. 

1.  Pyloric  stenosis  due  to  the  cicatrisation  of  a  simple  ulcer 
develops  very  gradually,  and  is  seldom  accompanied  by  rapid 
emaciation  or  cachexia.  There  is  almost  always  a  history  of 
previous  severe  pain  after  food,  with  one  or  more  attacks  of 
hgeniatemesis.  Pain  and  acidity  are  chiefly  experienced  during 
the  night,  and  the  vomit  may  be  stained  with  bile.  Free 
hydrochloric  acid  is  present  in  excess,  and  the  existence  of 
hypersecretion  may  be  determined  by  evacuating  the  stomach 
in  the  early  morning.  Although  the  viscus  may  be  greatly 
dilated  and  hypertrophied,  no  tumour  can  be  felt,  and  if  suitable 
treatment  is  adopted  the  general  health  may  continue  good  for 
many  years. 

2.  From  cancer  of  the  pylorus  the  diagnosis  is  very  difficult, 
since  the  symptoms  and  signs  of  the  two  diseases  are  practically 
identical.  It  is  stated,  however,  that  when  cancer  attacks  the 
upper  duodenum  the  appetite  is  less  affected  than  in  the  gastric 
complaint,  that  free  hydrochloric  acid  may  continue  for  a  con- 
siderable time,  that  bile  is  not  infrequent  in  the  vomit,  and  that 
diarrhoea  is  apt  to  alternate  with  constipation.  If  a  tumour  is 
present,  it  is  usually  situated  more  to  the  right  of  the  median 
line  than  is  the  case  with  a  pyloric  growth. 


298  TUMOUKS  OF  THE   STOMACH 

3.  Pressure  upon  the  first  part  of  the  duodenum  may  be 
caused  by  an  enlarged  gall-bladder,  a  tumour  of  the  liver,  an 
aneurysm  of  the  coeliac  axis  or  of  the  hepatic  artery,  or  by  a 
growth  of  the  omentum,  kidney,  pancreas,  or  retro-peritoneal 
glands.  These  forms  of  obstruction  develop  more  slowly  and 
are  less  severe  thau  that  produced  by  cancer  of  the  duodenum. 
Hsematemesis  and  cachexia  are  rare,  and  the  loss  of  flesh  is  often 
proportional  to  the  urgency  of  the  gastric  symptoms.  The 
tumour  varies  in  its  character  and  attachments  according  to  its 
mode  of  origin,  and  free  hydrochloric  acid  may  usually  be 
detected  in  the  gastric  contents. 

Malignant  disease  of  the  second  part  of  the  duodenum  may 
be  confused  with  cancer  of  the  pancreas  or  of  the  ampulla  of 
Vater,  with  gallstones,  and  with  a  simple  chronic  ulcer  in  the 
same  situation. 

1.  A  growth  of  the  head  of  the  pancreas,  or  of  the  small 
diverticulum  into  which  the  common  bile  and  pancreatic  ducts 
open  (ampulla  of  Vater),  is  accompanied  from  the  first  by 
jaundice,  which  soon  becomes  intense,  and  usually  persists 
throughout  the  whole  course  of  the  disease.  The  gastric 
phenomena,  on  the  other  hand,  are  of  subordinate  importance, 
and  mainly  consist  of  flatulence  after  meals,  a  bitter  taste  in 
the  mouth,  and  inability  to  digest  fats.  The  stomach  is  not 
dilated,  there  is  no  periodic  vomiting,  bile  is  absent  from  the 
stools,  and  the' secretion  of  hydrochloric  acid  usually  persists. 

2.  Gallstones  are  more  common  in  women  than  in  men, 
while  the  reverse  is  the  case  with  duodenal  cancer.  The  jaundice 
is  preceded  by  severe  spasmodic  pain,  and  may  continue  for 
several  months  without  seriously  affecting  the  general  health. 
Even  when  emaciation  is  a  marked  feature  of  the  case,  the 
patient  does  not  usually  display  that  loss  of  energy  and  physical 
debility  which  is  so  constant  in  cancer  of  the  digestive  organs. 
Periodic  vomiting,  with  the  signs  of  dilatation  of  the  stomach,  is 
absent,  there  is  no  hsematemesis  or  melsena,  and  the  initial 
enlargement  of  the  gall-bladder  disappears  after  a  short  time. 

3.  Simple  chronic  ulcer  of  the  duodenum  is  usually  accom- 
panied by  pain  some  hours  after  food,  with  tenderness  on 
pressure  above  and  to  the  right  of  the  navel,  and  by  occasional 
attacks  of  nielsena,  with  or  without  hsematemesis.  Loss  of 
flesh  and  appetite  is  an  unimportant  symptom,  and  the  degree 
of  anaemia  varies  with  the  severity  of  the  haemorrhage.     Should 


CAEOINOMA  AND   SAECOMA   OF  THE   DUODENUM    299 

the  disease  ultimately  produce  stenosis  of  the  bowel,  the  gastric 
dilatation  is  accompanied  by  hyperchlorhydria. 

Obstruction  of  the  third  part  of  the  duodenum  may  arise 
from  other  causes  than  malignant  stricture,  since  a  tumour  of 
any  neighbouring  viscus  may  exert  pressure  upon  the  bowel. 
It  is  also  possible  that  undue  tension  of  the  transverse  meso- 
colon, or  enlargement  of  the  superior  mesenteric  vessels,  may 
compress  this  portion  of  the  gut.  Of  the  internal  diseases,  the 
impaction  of  a  gall-stone  and  the  cicatrisation  of  a  simple  ulcer 
are  the  most  important.  In  all  these  cases,  however,  the  ante- 
cedent symptoms  differ  greatly  from  those  of  duodenal  carci- 
noma ;  there  is  seldom  cachexia  or  rapid  loss  of  flesh,  and 
the  discovery  of  a  tumour  helps  to  elucidate  the  nature  of  the 
primary  disease.  A  gastro-biliary  fistula  is  also  accompanied 
by  vomiting  of  bile,  but  there  is  usually  a  history  of  gallstones, 
while  dilatation  of  the  stomach  and  duodenum  is  absent. 

Treatment. — This  must  be  conducted  upon  the  same  lines 
as  that  of  cancer  of  the  pylorus.  Lavage  should  be  performed 
night  and  morning,  the  bowels  maintained  in  regular  action, 
and  the  diet  adjusted  to  the  necessities  of  the  patient.  Excision 
of  the  growth  is  rarely  feasible,  but  gastro-enterostomy  often 
prolongs  life  for  several  months. 


BIBLIOGRAPHY 

Arrachard,  Gaz.  des  Hopitaux,  1860,  p.  98. 

Atkinson,  Pepper's  System  of  Medicine,  ii.  p.  868. 

Avezon,  Bullet.  Soc.  Anatorn.,  1875,  p.  465. 

Boas,  Berlin,  klin.  Wochensch.,  1891,  p.  949. 

Bright,  Arch.  Gen.  de  Med.,  1834. 

Bryant,  J.  D.,  Annals  of  Surgery,  1893. 

Busson,  Du  Cancer  de  l'Ampoule  de  Vater.     These  de  Paris,  1893. 

Gaillet,  De  quelques  Cas  dTctere  Mecanique  dus  au  Cancer  de  la  2e  portion  du 

Duodenum.     These  de  Paris,  1876. 
Charon  &  Ledecjank,  Journ.  de  Med.,  Chir.  et  de  Pharm.,  1879,  p.  493. 
Chomel,  Gaz.  des  Hopitaux,  1852,  p.  37. 
Cockle,  Medical  Times,  1883,  p.  435. 

Damaschino,  Traite  de  Maladies  des  Voies  Digestives,  1880,  p.  847. 
Dickinson,  New  York  Med.  Journ.,  1879,  30,  p.  149. 
Dictionnaire  Encyclopedique  des  Sciences  Medicales,  12,  p.  576. 
Durand-Fardel,  Archives  Gen.  de  Med.,  1840,  p.  167. 
Einhorn,  Diseases  of  the  Intestines,  p.  159. 
Fenwick,  Soltau,  Edinb.  Med.  Journal,  1901,  4,  p.  309. 
Feriol,  Soc.  Medicale  d'Observation  de  Paris,  1850. 
Frerichs,  Traite  des  Maladies  du  Foie. 


300  TUMOUES  OF  THE   STOMACH 

Grisolle,  cited  by  Atkinson,  op.  cit. 

Haassmann,  Etiologie  et  Pathogenie  du  Cancer  de  l'lntestine.     These  de  Paris, 

1882. 
Lannois  &  Courmont,  Eevue  de  Med.,  1894,  p.  292. 
Maydl,  Ueber  den  Damikrebs,  Wien,  1883. 
Nattan-Larrier,  Gaz.  des  Hopitaux,  1899,  p.  1311. 

Nothnagel,  Die  Erkrankungen  des  Darms  u.  des  Peritoneums,  Wien,  1898. 
Pic,  Eevue  de  Medecine,  14,  p.  1081. 
Pye-Smith,  Trans.  Path.  Soc.  45,  p.  63. 
Bolleston,  Lancet,  1901,  i.  p.  1121. 
Schlesinger,  Wien.  klin.  Wochensch.,  1898,  10,  p.  245. 
Sibley,  Med.-Chir.  Trans.,  1059,  p.  111. 
Tanchou,  Ziemssen's  Cyclop.,  7,  p.  432. 
WJiittier,  '  Primary  Malignant  Disease  of   the  Duodenum,'  Trans.  Assoc.  Amer. 

Phys.,  1889,  p.  292. 

Sabcoma  op  the  Duodenum 
Libman  (full  literature),  American  Journal  Med.  Science,  vol.  exx.  p.  309. 


301 


CHAPTEE    III 

POLYPI  AND  PEDUNCULATED  TUMOUBS 
OF  THE  STOMACH 

Polypoid  tumours  are  occasionally  met  with  in  the  stomach, 
and  may  be  classified  according  to  their  histological  structure 
as  pedunculated  adenomata,  fibromata,  lipomata,  and  myomata. 
The  so-called  '  mucous  polypus '  is  really  a  small  adenoma 
which  has  undergone  cystic  changes,  but  since  it  differs  con- 
siderably from  the  ordinary  form  of  that  disease  it  is  convenient 
to  describe  it  as  a  separate  variety. 

(1)  Mucous  Polypi  (Polyadenomata).— These  tumours 
appear  to  be  more  common  on  the  continent  of.  Europe  than 
in  England  or  America,  since  Ebstein  met  with  fourteen  cases  in 
600  necropsies  (2-3  per  cent.),  while  in  London,  according  to 
our  statistics,  their  frequency  of  occurrence  does  not  exceed  0'2 
per  cent.  Out  of  thirty-four  cases  which  we  have  collected  from 
various  sources  the  tumour  was  solitary  in  fourteen,  or  41  per 
cent.,  while  in  the  remaining  twenty,  or  59  per  cent.,  the 
number  varied  from  six  to  200  (Cruveilhier,  Eoullier,  Brissaud, 
Leudet).  A  single  polypus  is  usually  situated  near  the  pylorus, 
but  in  the  multiple  form  of  the  disease  the  fundus  and  central 
portions  of  the  viscus  in  the  vicinity  of  the  great  curvature  are 
principally  affected.  As  a  rule  the  tumours  are  distributed 
evenly  over  the  two  surfaces,  but  occasionally  they  are  collected 
into  groups  of  five  or  more  (Cruveilhier),  or  are  arranged  in  rows 
which  run  parallel  with  the  long  axis  of  the  organ  (Eichard). 
The  intervening  mucous  membrane  may  be  quite  healthy,  or 
it  may  present  numerous  hemispherical  swellings  about  the 
size  of  a  split  pea,  which  represent  the  disease  in  its  rudi- 
mentary form.  It  is  not  uncommon  to  find  a  single  polypus 
surrounded  by  several  others  in  the  process  of  formation. 

As  a  rule  the  mucous  polyp  is  globular  or  slightly  lobulated, 


302 


TUMOUES   OF  THE   STOMACH 


and  looks  like  a  small  nut  attached  to  the  surface  of  the  stomach 
by  a  short  flat  stalk  ;  but  it  may  be  cylindrical  or  club-shaped, 

or  it  may  present  the  appear- 
ance of  a  mushroom.  The 
solitary  tumour  may  measure 
from  one  to  four  inches  in 
length  (Ebstein)  ;  but  when 
several  exist  the  individual 
polypi  are  remarkably  uni- 
form in  size  and  seldom  ex- 
ceed three-quarters  of  an  inch. 
The  colour  varies,  according 
to  the  degree  of  vascularity, 
from  a  bright  pink  to  a  pale 
brown,  and  the  surface,  when 
freed  from  adherent  mucus,  is 
often  found  to  be  irregular  and 
pigmented.  The  consistence 
is  soft  and  slimy,  and  when 
firmly  squeezed  a  large  quan- 
tity of  greyish  mucus  exudes 
from  the  tissue  and  the 
tumour  is  reduced  to  about 
one  third  of  its  original  size. 
Occasionally  the  duodenum 
and  ileum,  or  even  the  whole 
of  the  intestinal  tract,  are 
affected  in  a  similar  manner. 
On  microscopical  examina- 
tion the  centre  of  the  tumour 
is  found  to  consist  of  a  strip 
of  connective  tissue,  which  is 
continuous  with  the  sub- 
mucous coat  of  the  stomach 
and  contains  blood  -  vessels 
and  lymphatics.  Over  this 
is  spread  a  layer  of  unstriped 
muscle,  which  represents  the 
muscularis  mucosae  in  an 
The  great  bulk  of  the  growth  is 
membrane,    which    is    from    five    to 


Fig.  61. — Mucous  polypi  in  the  stomach. 
(Museum  of  the  Eoyal  College  of 
Surgeons.) 


hypertrophied    state, 
composed    of    mucous 


POLYPI  AND  PEDUNCULATED  TUMOUES 


303 


twelve  times  its  normal  thickness.  The  free  surface  often 
presents  a  papillary  appearance,  owing  to  hypertrophy  of  the 
connective  tissue  between  the  mouths  of  the  ducts,  and  is 
sometimes  covered  with  cylindrical  epithelium.  The  gastric 
glands  are  elongated,  dilated,  and  tortuous,  and  here  and  there 
are  converted  into  large  cysts  filled  with  mucus.  These  dilated 
glands  closely  resemble  the  uriniferous  tubules  in  the  cortical 
portion  of  the  kidney,  being  provided  with  a  distinct  basement 
membrane  and  lined  by  cubical  or  cylindrical  epithelium,  while 
in  the  cysts  the  cells  are  often  rounded  and  vacuolated. 
Menetrier  distinguishes  two  varieties,  according  as  the  ducts 
or  the  fundi  of  the  glands  are  chiefly  affected.  In  the  former 
case  the  tumour  is  distinctly  lobulated  and  the  cysts  are 
numerous  and  large,  owing  to  obstruction  of  the  mouths  of  the 
ducts  by  fusion  of  the  papillary  processes  between  them.  In 
the  latter  there  is  little  or  no  lobulation,  and  cysts  are  either 
few  in  number  or  entirely  absent.  The  intervening  mucous 
membrane  presents  the  usual  signs  of  chronic  inflammation, 
and  its  vessels  are  occasionally  lardaceous. 

Very  little  is  known  with  regard  to  the  etiology  of  the 
disease.  Out  of  thirty-two  cases  in  which  the  sex  of  the 
patient  was  stated,  twenty-two  were  males  and  ten  were 
females.  The  complaint  is  rare  before  the  age  of  forty,  but 
the  tendency  to  it  seems  to  increase  with  advancing  age.  This 
fact  is  shown  in  the  following  table. 


Table   36 


Age                                              No.  of  cases 

Percentage 

Under  twenty-five 
Thirty  to  forty  . 
Forty  to  fifty 
Fifty  to  sixty 
Sixty  to  seventy 
Seventy  to  eighty 
Eighty  to  ninety 

1 
3 

7 
8 
6 
2 
2 

3-4 
10-3 
24 
27-6 
20-7 

7 

7 

Total          .... 

29 

100 

Andral  and  Cruveilhier  regarded  a  polypoid  condition  of 
the  gastric  mucous  membrane  as  a  result  of  chronic  inflamma- 
tion, and  Camus-Govignon  considered  that  the  abuse  of  alcohol 
was  an  important  factor  in  its  causation  ;  but  in  a  large  propor- 
tion of  the  recorded  cases  there  was  no  history  of  indulgence 


304  TUMOURS   OF  THE   STOMACH 

in  alcohol  (Quinquaud,  Richard,  Liouville).  In  several  instances 
the  patient  was  either  a  lunatic  or  subject  to  epilepsy,  and  in 
such  the  disease  often  developed  at  an  unusually  early  age 
(Barr  Stevens,  Norman).  According  to  Menetrier  the  gastric 
complaint  is  often  associated  with  fibroid  tumours  of  the 
uterus  or  ovaries,  and  with  atheroma  of  the  large  arteries. 

(2)  Pedunculated  Adenomata. — These  occur  in  the  form 
of  round,  smooth,  or  lobulated  tumours,  of  a  greyish-brown 
colour  and  firm  consistence,  which  are  attached  by  short  thick 
stalks  to  the  mucous  membrane  in  the  pyloric  region.  "When 
solitary  they  may  attain  the  size  of  an  apple,  or  even  of  the 
foetal  head  at  term  (Chaput),  but  if  several  exist  they  seldom 
exceed  the  dimensions  of  a  walnut  and  may  be  as  small  as 
peas.  In  one  instance  which  came  under  our  observation  four 
pedunculated  adenomata,  each  as  large  as  a  pigeon's  egg,  were 
found  attached  to  the  margin  of  the  pyloric  ring,  and  had 
produced  partial  obstruction  of  the  orifice.  On  section  the 
growth  is  firm  and  smooth,  and  sometimes  presents  several 
small  cysts  filled  with  brownish  mucus.  Under  the  micro- 
scope it  is  found  to  consist  of  tubular  glands,  supported  by 
connective  tissue  and  well  supplied  with  blood-vessels,  while 
the  mucous  membrane  which  covers  it  is  affected  by  chronic 
interstitial  inflammation. 

It  is  often  impossible  to  draw  a  hard  and  fast  line  between 
a  large  adenoma  and  an  adeno-carcinoma,  since  the  structure 
may  be  very  similar  in  the  two  cases  and  death  may  occur  in 
the  malignant  disease  before  the  formation  of  metastases.  It 
is  also  probable  that  a  simple  adenoma  sometimes  assumes  a 
malignant  character.  Thus,  Ferguson  has  recorded  the  case  of 
a  woman,  aged  forty-three,  who  suffered  for  about  a  year  from 
pain  after  food,  vomiting,  and  haematemesis,  and  presented  an 
ill-defined  tumour  in  the  epigastrium.  After  death  the  region 
of  the  lesser  curvature  of  the  stomach  was  found  to  be 
occupied  by  a  large  soft  growth  covered  with  excrescences, 
which  extended  a  short  distance  up  the  oesophagus  and  had 
caused  adhesions  between  the  stomach  and  the  under  surface 
of  the  liver.  Although  microscopical  investigation  is  said  to 
have  proved  that  the  growth  was  a  simple  adenoma,  the 
clinical  aspect  of  the  case  and  the  naked-eye  appearances  of  the 
disease  clearly  indicate  that  it  was  malignant  in  its  nature.  A 
similar  criticism  may  be  passed  upon  Lange's  case,  where  a 


POLYPI  AND  PEDUNCULATED  TUMOUES 


305 


deep  ulcer  on  the  anterior  wall,  surrounded  by  extensive  infil- 
tration, is  said  to  have  arisen  from  the  disintegration  of  a  simple 
adenoma,  and  as  an  example  of  such  is  usually  cited. 

(3)  Fibromata,  like  the  preceding  variety,  may  be  either 
single  or  multiple.  They  usually  occur  in  the  pyloric  end 
of  the  stomach,  and  are  often  attached  to  the  edge  of  the 
valve.  As  a  rule  they  are  elongated  or  club-shaped,  and 
measure  from  one  to  four  inches  in  length  (Bernabei),  but 
they  sometimes  assume  a  round  or  chestnut  shape.  The  surface 
may  be  smooth,  lobulated,  warty,  or  distinctly  villous,  and  the 


Fig.  62. — Pedunculated  fibroma  attached  to  the  edge  of  the 
pyloric  orifice.     (London  Hospital  Museum.) 


pedicle  is  often  of  the  same  diameter  as  the  tumour.  Micro- 
scopically, they  either  present  a  papillomatous  structure  or 
consist  entirely  of  fibrous  tissue  covered  with  thin  mucous 
membrane. 

(4)  Pedunculated  Lipomata  are  much  rarer  than  the  pre- 
ceding varieties  and  are  usually  solitary.  The  growth  is 
commonly  situated  in  the  central  portion  of  the  stomach  and 
on  the  anterior  wall,  where  it  forms  a  soft  lobulated  tumour  of 
a  pale  yellow  colour  with  a  short  thick  pedicle.  In  one  of  our 
cases  the  tumour  measured  two  inches  in  length  and  two  and 
a  quarter   inches  in  thickness  ;    while    in   another   it   closely 

x 


306 


TUMOUES  OF  THE   STOMACH 


resembled  a  thumb  in  size  and  shape.  In  rare  instances  a 
submucous  lipoma  passes  through  the  muscular  coat  and 
forms  a  pendulous  tumour  of  considerable  size  beneath  the 
serous  investment  of  the  stomach  (Orth,  Eussdorf).  Micro- 
scopically it  is  found  to  consist  of  fat  mixed  with  fibrous  tissue 
and  covered  by  thin  mucous  membrane. 

(5)  Pedunculated     Myomata    take    the    form     of     firm 
rounded  tumours,  which  vary  from  the  size  of  a  pea  to  that  of 


Fig.  63. — A  pedunculated  fibroma  with  a  long  pedicle  (natural  size). 


a  cherry,  and  are  attached  to  the  wall  of  the  stomach  bj^  a  thin 
pedicle.  They  may  be  single  or  multiple,  and  are  usually 
situated  in  the  pyloric  region.  They  consist  of  unstriped 
muscle-fibres,  which  are  arranged  in  a  concentric  manner  and 
covered  by  attenuated  mucous  membrane. 

Symptoms. — The  symptoms  that  accompany  polypoid 
tumours  of  the  stomach  vary  according  to  the  size  and  situa- 
tion of  the  growth.  In  nearly  one  half  of  the  cases  where  the 
fundus  or  central  portion  of  the  viscus  was  affected  by  mucous 


POLYPI  AND  PEDUNCULATED   TUMOUES  307 

polypi,  no  symptoms  whatever  were  observed  during  life,  while 
in  the  rest  the  patients  merely  suffered  from  discomfort  after 
meals,  want  of  appetite,  gradual  loss  of  flesh,  or  from  some 
other  indication  of  disordered  digestion.  When,  however,  the 
pyloric  region  was  involved  by  the  disease,  gastric  phenomena 
wTere  almost  always  present.  As  a  rule  the  principal  cause  of 
complaint  was  epigastric  pain,  which  was  either  persistent  and 
unaffected  by  food,  or  was  only  experienced  during  the  period  of 
digestion.  Less  frequently  the  patient  was  subject  to  sudden 
and  violent  attacks,  which  persisted  from  a  few  minutes  to 
several  hours  and  were  accompanied  by  retching  and  vomiting. 
In  these  latter  cases  there  was  usually  a  polypus  of  considerable 
length  situated  near  the  pylorus,  the  free  extremity  of  which 
occasionally  prolapsed  through  the  valve  and  suffered  tem- 
porary strangulation. 

Case  XXV.  A  man,  fifty-seven  years  of  age,  complained  for  a  long 
time  of  severe  attacks  of  pain  in  the  epigastrium,  which  were 
accompanied  by  nausea  and  vomiting.  These  symptoms  occurred  at  ir- 
regular intervals  some  hours  after  a  meal,  and  lasted  from  a  few  minutes 
to  two  or  three  hours.  Each  attack  terminated  suddenly  and  was 
followed  by  rumbling  and  gurgling  over  the  site  of  the  pain.  The 
patient  became  very  anaemic,  and  died  from  acute  peritonitis.  At 
the  necropsy  the  stomach  was  found  to  be  somewhat  dilated,  and 
a  small  perforation  was  present  at  the  upper  and  anterior  part  of  the 
pylorus.  Three  inches  from  the  orifice,  and  attached  to  the  lower 
border  of  the  organ,  there  was  a  fibrous  polypus  as  thick  as  the  little 
finger  and  about  three  inches  long.  It  seemed  probable  that  the 
occasional  entanglement  of  the  tumour  in  the  pyloric  opening  had 
occasioned  the  spasmodic  pain  ,and  other  symptoms  observed  during 
life. — Gleghom. 

In  other  cases  periodic  vomiting  arising  from  obstruction  of 
the  pylorus  is  the  principal  feature  of  the  complaint.  In 
Cruveilhier's  case  the  orifice  was  almost  obliterated  by  the 
tumour  and  the  stomach  was  greatly  dilated,  while  in  that 
recorded  by  Barr  Stevens  a  dense  mass  of  mucous  polypi, 
covering  an  area  three  inches  square,  appeared  to  have  acted  as 
a  ball-valve  during  life.  In  this  instance  the  patient  was  the 
subject  of  epilepsy,  and  always  experienced  an  aura  referable  to 
the  stomach  at  the  commencement  of  a  fit.  In  one  of  our  cases 
there  was  a  long-standing  complaint  of  flatulence  and  acidity, 
but  owing  to  the  incomplete  nature  of  the  obstruction  vomit- 

x  2 


308  TUMOUES  OF  THE   STOMACH 

ing  occurred  only  at  intervals.  Chemical  examination  of  the 
ejecta  does  not  afford  any  clue  to  the  nature  of  the  disease, 
but  in  the  following  case  the  diagnosis  was  easily  made  by  the 
appearance  of  a  detached  polypus  in  the  vomit. 

Case  XXVI.  A  female,  aged  nineteen,  of  robust  appearance,  bad 
enjoyed  good  health  until  twelve  months  ago,  when  she  had  an 
attack  of  herpes  zoster  on  the  left  side.  A  short  time  afterwards  she 
began  to  suffer  from  distension  of  the  stomach  and  pain  after  meals. 
At  first  the  pain  was  only  slight  and  occasional,  but  subsequently  it 
became  very  bad,  and  was  especially  troublesome  at  night.  For  the 
last  three  months  she  had  lost  much  flesh — a  stone  and  a  half  in 
six  weeks.  She  often  felt  faint  with  the  pain  in  the  stomach,  which 
had  also  extended  to  the  left  side.  The  bowels  were  regular.  One 
day,  while  going  about  her  usual  work,  she  suddenly  felt  faint  and 
vomited  a  small  tumour.  At  the  time  of  its  rejection  another 
appeared  to  be  rising  in  her  throat,  but  she  swallowed  it  again. 
After  the  emesis  she  felt  poorly  all  day,  and  on  several  occasions 
ejected  a  small  quantity  of  blood.  The  tumour  itself  was  about  the 
size  of  a  chestnut,  and  appeared  to  have  been  attached  by  a  small 
pedicle  to  the  mucous  membrane  of  the  stomach.  It  was  firm  and 
looked  like  an  unshelled  egg.  The  cut  surface  showed  several  small 
foramina,  and  on  microscopical  examination  it  was  found  to  consist 
of  connective  tissue,  blood-vessels,  and  granular  cells,  covered  by  a 
layer  of  mucous  membrane. — Bearclsley. 

Haemorrhage  occurs  in  about  10  per  cent,  of  the  cases. 
When  it  is  due  to  excessive  vascularity  of  the  growth  or  of  the 
surrounding  mucous  membrane,  the  vomit  is  merely  tinged 
with  blood,  or  exhibits  a  slight  coffee-ground  appearance ;  but 
when  a  large  vessel  has  been  eroded  by  ulceration  or  sloughing 
of  the  tumour  the  loss  of  blood  may  be  serious  and  recurrent 
(Eondeau,  Ellison). 

Large  adenomata  are  always  accompanied  by  important 
gastric  symptoms.  If,  as  is  usually  the  case,  the  tumour 
occupies  the  pyloric  region  of  the  stomach,  pain  after  food, 
with  flatulence,  acidity,  and  vomiting,  are  the  chief  causes  of 
complaint  ;  and  should  the  pyloric  orifice  ultimately  become 
obstructed,  periodic  attacks  of  emesis,  accompanied  by  loss  of 
flesh,  anorexia,  and  cachexia,  gradually  make  their  appearance, 
and,  unless  the  disease  proves  amenable  to  treatment,  eventually 
lead  to  a  fatal  issue.  When  the  central  portion  or  the  fundus  is 
the  seat  of  the  disease,  there  is  usually  severe  pain  after  food  ; 


POLYPI  AND  PEDUNCULATED   TUMOUES  309 

vomiting  and  haemateniesis,  or  melsena,  occur  from  time  to  time, 
and  the  patient  develops  the  emaciated  and  cachectic  appear- 
ance which  is  usually  indicative  of  a  cancerous  growth. 

Case  XXVII.  A  man,  aged  sixty-four,  was  admitted  into  hospital 
with  the  following  history.  Nine  months  previously  he  had  begun 
to  experience  discomfort  after  meals  with  colicky  pains  and  excessive 
flatulence.  After  continuing  in  this  state  for  seven  months  he  had 
been  suddenly  attacked  by  hsematemesis,  which  lasted  for  two  days. 
Since  that  time  he  had  suffered  severe  pain  after  food,  had  lost  his 
appetite,  and  had  frequently  vomited.  He  had  also  become  much 
emaciated  and  very  weak,  and  had  noticed  a  tumour  in  the  abdomen 
for  nearly  three  months. 

On  examination  the  patient  was  found  to  be  extremely  thin  and 
markedly  cachectic.  In  the  epigastrium  a  large  tumour  could  be  seen, 
which  extended  from  the  left  costal  margin  to  the  right  of  the  median 
line  and  downwards  to  the  level  of  the  umbilicus.  On  palpation  it 
had  a  hard  smooth  surface,  could  be  easily  moved  from  side  to  side, 
and  to  a  lesser  degree  in  the  vertical  direction,  and  was  resonant  on 
percussion.  No  fluctuation  could  be  detected  in  it,  and  manipulation 
gave  rise  to  pain.     There  were  no  signs  of  dilatation  of  the  stomach. 

Cancer  of  the  parietes  of  the  stomach  was  diagnosed,  and  an 
operation  was  undertaken  with  a  view  to  its  removal.  When  the 
anterior  wall  of  the  organ  had  been  incised,  a  large  pedunculated 
tumour  was  found  attached  to  the  posterior  surface.  The  pedicle 
was  cut  and  the  mass  removed,  the  patient  making  an  excellent 
recovery.  The  tumour  itself  was  the  size  of  the  foetal  head  at  term, 
and  presented  a  lobulated  surface  and  a  short  thick  stalk.  The 
section  showed  numerous  small  cysts,  and  microscopical  examination 
proved  it  to  be  a  simple  adenoma. — Ghaput. 

Duration  and  Complications. — Mucous  polypi  affecting  the 
region  of  the  great  curvature  do  not  appear  to  influence  the 
duration  of  life,  since  in  nearly  one  third  of  the  recorded 
examples  the  patient  attained  the  age  of  sixty  years.  In  those 
cases,  however,  where  urgent  symptoms  existed,  or  where  the 
pedunculated  tumour  was  of  large  size,  the  disease  helped 
materially  to  shorten  the  period  of  existence.  In  most  instances 
the  fatal  result  was  due  to  exhaustion  arising  from  pain  and 
vomiting.  Fatal  haemorrhage  has  only  once  been  recorded 
(Ellison),  and  the  same  remark  applies  to  the  frequency  of  per- 
foration. The  most  important  sequela  is  carcinoma.  Lemaitre 
has  recorded  a  case  in  point,  and  Menetrier  has  made  some 
important  observations  upon  the  mode  of  development  of  the 


310  TUMOUES   OF  THE   STOMACH 

malignant  disease.  In  one  case  of  multiple  polypi  which  came 
under  his  notice  a  deep  ulcer  the  size  of  a  five-franc  piece  with 
an  irregular  pulpy  base  was  found  upon  the  lesser  curvature. 
On  microscopical  examination  the  sides  of  the  ulcer  showed 
hypertrophied  gland  tissue  similar  to  that  in  the  polypi,  but 
at  the  base  the  tubular  processes,  instead  of  being  confined 
to  the  mucous  membrane,  were  seen  to  have  penetrated  the 
muscularis  mucosae  and  to  ramify  in  the  submucous  coat.  The 
epithelium  presented  an  atypical  appearance,  and  secondary 
deposits  of  adeno-carcinoma  were  found  in  the  lymphatic  glands 
and  in  the  liver.  In  another  case,  where  the  adenomatous 
disease  occurred  as  a  raised  patch  in  the  gastric  wall  {en  nappe), 
the  various  gradations  between  simple  adenoma  and  carcinoma 
could  be  easily  traced.  Spontaneous  cure  of  the  polypoid  con- 
dition may  be  brought  about  by  detachment  of  the  growths 
(Beardsley),  while  a  similar  affection  of  the  small  intestine 
may  lead  to  fatal  intussusception,  as  in  the  following  case  : — 

Case  XXVIII,  A  man,  aged  twenty-one,  was  admitted  into  the 
Eadcliffe  Infirmary  on  June  28,  1895.  His  illness  commenced  about 
twelve  months  previously  with  pain  across  the  upper  part  of  the 
abdomen  and  vomiting.  These  symptoms  had  increased  in  severity 
during  the  last  six  months.  On  one  or  two  occasions  the  vomit 
was  blood-streaked.     Eain  did  not  seem  to  be  affected  by  food. 

On  admission  the  patient  looked  anxious  and  very  ill.  Nothing 
was  discovered  in  the  abdomen  to  account  for  the  pain  and  vomiting. 
W  hile  in  the  infirmary  he  vomited  daily,  and  often  complained  of 
severe  abdominal  pain.  Bowels  confined.  He  was  put  on  a  fluid 
diet. 

On  the  evening  of  -July  10  the  patient  was  seized  with  more  than 
usually  severe  pain,  and  the  vomiting  became  urgent.  The  following 
morning  a  distinct  tumour  could  be  made  out,  running  obliquely 
across  the  abdomen  from  right  to  left.  This  was  considered  to  be 
most  probably  an  intussusception,  and  it  was  decided  to  open  the 
abdomen.  On  this  being  done  a  large  intussusception  was  found, 
commencing  a  few  inches  from  the  pylorus.  It  was  easily  reduced, 
but  the  patient's  condition  did  not  improve,  and  he  'died  about 
twenty-four  hours  after  the  completion  of  the  operation. 

July  12. — On  post-mortem  examination  an  enormous  number  of 
polypi  were  found,  varying  in  size  horn  a  pigeon's  egg  to  a  pea ;  they 
were  scattered  throughout  the  stomach  and  small  intestines,  the 
greatest  number  being  in  the  duodenum  and  upper  part  of  the 
jejunum.  Many  of  them  were  furnished  with  long  pedicles  (fig.  61). 
TT".  Collier. 


POLYPI  AND  PEDUNCULATED  TUMOUES  311 

Diagnosis. — Multiple  small  polypi  in  the  stomach,  being 
rarely  accompanied  by  any  symptoms  of  importance,  can  seldom 
be  recognised  during  life.  In  the  only  two  cases  where  a  success- 
ful diagnosis  was  made  unmistakable  evidence  of  the  disease 
was  afforded  by  the  appearance  of  a  polypus  in  the  vomit.  In 
Beardsley's  case,  already  cited,  the  tumour  was  apparently 
detached  during  an  attack  of  violent  retching,  while  in  the  other 
it  became  entangled  in  the  eye  of  a  stomach-tube,  and  was  thus 
removed  (Debove).  Even  when  the  pylorus  is  partially 
obstructed  no  tumour  can  be  detected,  and  the  concomitant 
pain  and  hseniatemesis  usually  suggest  the  presence  of  an  ulcer 
rather  than  of  a  growth. 

Pedunculated  adenomata  accompanied  by  a  palpable  tumour 
are  exceedingly  rare,  and  closely  resemble  cancer  or  fibro- 
sarcoma of  the  stomach.  Indeed,  notwithstanding  the  cases 
of  benign  adenomata  recorded  by  Chaput,  Hinds,  and  others, 
we  are  strongly  of  the  opinion  that  all  palpable  tumours 
occurring  after  middle  life  and  accompanied  by  progressive 
symptoms  are  really  malignant  in  character. 

Treatment. — This  resolves  itself  into  the  treatment  of 
symptoms.  If  the  stomach  is  dilated  the  employment  of  lavage 
with  an  appropriate  diet  will  afford  relief,  while  in  cases  where 
spasmodic  pain  is  a  prominent  feature  of  the  disease  recourse 
must  be  had  to  opiates.  The  presence  of  a  movable  tumour 
connected  with  the  stomach  should  be  regarded  as  an  indica- 
tion for  surgical  interference. 

BIBLIOGRAPHY 

Alin,  Upsala  Lakaref.  Porh.,  1884,  p.  177. 

Amatus  Lusitanus,  Curat,  medic.  Centurise  septern,  23,  1557. 

Andral,  Grundriss  der  path.  Anatornie,  ii.  p.  33,  1830. 

Barth,  Bull.  Soc.  Anat.,  1847,  p.  212. 

Beardsley,  Trans.  Path.  Soc,  viii.  p.  219. 

Bernabei,  Virch.  Jahrb.,  1882,  ii.  p.  162. 

Blain  de  Cominiers,  Bull.  Soe.  Anat.,  1847,  p.  399. 

Brissaud,  Arch.  Gen.  de  Med.,  1885,  p.  257. 

Caron,  Bull.  Soc.  Anat.,  1855,  p.  984. 

Chaput,  ibid.,  1895,  p.  534. 

Cleghorn,  New  Zealand  Med.  Journ.,  1892,  p.  55. 

Collier,  Path.  Soc.  Trans.,  xlvii.  p.  46. 

Cornil,  Gaz.  des  Hopitaux,  1864,  p.  20. 

Cruveilhier,  Anat.  Pathol,  du  Corps  Humain,  xxii.  pi.  lvi. 

Cutler,  Boston  Med.  and  Surg.  Journ.,  1879,  p.  513. 


312  TUMOUES  OP  THE   STOMACH 

Ebstein,  Arch.  f.  Anat.  u.  Physiol.,  1864,  p.  94. 
Ellison,  Australian  Med.  Journ.,  1871,  p.  284. 
Forster,  Handb.  der  pathol.  Anatomie,  1862. 
Govignon,  Polypes  de  l'Estomae.     These,  Paris  1883. 

Hinds,  quoted  by  Bobson  and  Moynihan.  Diseases  of  the  Stomach,  p.  53. 
Lcmibl,  Beobachtungen  aus  dern  Franz  Joseph  Kinderspital,  1860,  p.  376. 
Lange,  New  York  Med.  Journ.,  1892,  55,  p.  584. 

Lebert,  Traite  d'Anatomie  Pathol.  Generale  et  Spec,  i.  p.  268  ;  ii.  p.  180,  1857. 
Lemaitre,  Bull.  Soc.  Anat.,  1850,  p.  179. 
Leudet,  ibid.,  1847,  p.  206. 
Liouville,  Bull.  Soc.  Anat.,  1864,  p.  63. 
Liischka,  Yirchow's  Archiv,  xx.  p.  133. 
M6n6trier,  Arch,  de  Phys.,  1888,  ii.  p.  32. 
Morgagni,  De  Sede  et  Caussis  Morborum,  Epistol.  xvi. 
Norman,  Dub.  Journ.  Med.  Sci.,  1893,  p.  346. 
Quinguaud,  cited  by  Brissaud. 
Richard,  Bull.  Soc.  Anat.,  1846,  p.  209. 
Bipault,  ibid.,  1833,  p.  63. 

Rocliester,  Buff.  Med.  and  Surg.  Journ.,  1S69,  p.  167. 
Bokitansky,  Lehrb.  der.  path.  Anat.,  1861,  iii.  p.  154. 
Bondeau,  Ann.  Soc.  d'Anat.  Path,  de  Brux.,  xxx.  p.  142. 
Roullier,  cited  by  Govignon. 
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313 


CHAPTEE    IV 

SYPHILIS   OF  THE   STOMACH 

Syphilis  may  affect  the  stomach  in  three  ways  :  (1)  By  the 
formation  of  gunimata  ;  (2)  by  the  production  of  endarteritis  ; 
and  (3)  by  exciting  chronic  inflammation  of  its  mucous  mem- 
brane. 

(1)  Gummata. — A  gumma  of  sufficient  size  to  attract  atten- 
tion is  rarely  encountered.  Chiari  observed  only  three  in- 
stances in  243  necropsies  upon  persons  suffering  from  syphilis, 
and  in  all  about  sixteen  genuine  examples  are  recorded  in  the 
literature  of  the  subject.  The  tumour,  which  is  often  multiple, 
is  usually  situated  in  the  submucous  tissue  of  the  pyloric 
region,  near  the  lesser  curvature.  It  is  round  and  somewhat 
flattened  on  the  surface,  yellowish  in  colour,  firm  on  section,  and 
varies  from  three  to  seven  centimetres  or  more  in  diameter.  At 
first  the  mucous  membrane  which  covers  it  is  stretched  and  thin, 
but  as  the  nodule  increases  in  size  and  its  substance  undergoes 
softening  it  usually  becomes  destroyed  and  an  ulcer  is  produced. 
A  gummatous  ulcer  consequently  presents  certain  features 
which  serve  to  distinguish  it  from  the  simple  variety.  In 
shape  it  is  often  irregular,  scalloped,  or  even  triangular ;  its 
edges  are  thickened  and  undermined  ;  while  its  walls  and  base 
are  shaggy,  cheesy,  hemorrhagic,  or  covered  with  a  firmly 
adherent  yellow  slough.  The  mucous  membrane  in  the  vici- 
nity of  the  neoplasm,  or  its  resultant  ulcer,  exhibits  signs  of 
chronic  inflammation  and  is  not  infrequently  studded  with 
minute  gummata.  Perforation  of  the  stomach  has  not  been 
observed,  although  in  a  case  recorded  by  Lancereaux  this 
accident  was  prevented  only  by  the  presence  of  a  cheesy 
nodule.  It  is  important  to  observe  that  in  all  these  cases 
manifestations  of  syphilis  were  present  in  the  other  abdominal 
viscera,  the  liver,  pancreas,  spleen,  or  lymphatic  glands  pre- 


314  TUMOUES  OP  THE   STOMACH 

senting  gummata  or  cicatrices.  In  cases  of  congenital  syphilis 
in  newly  born  infants  the  small  intestine  is  particularly  apt  to 
suffer,  and  small  gummata  may  often  be  found  scattered 
throughout  its  length  or  congregated  about  the  ileo-csecal 
valve.  Similar  conditions  have  also  been  described  in  the 
foetus  (Bittner). 

(2)    Endarteritis. — Obliterative   endarteritis   affecting   the 
gastric  vessels  must  not  be  regarded  as  necessarily  an  indication 
of  syphilis.     It  may  be  observed  in  the  fibrous  base  of  nearly 
every  chronic  simple  ulcer,    and  in  not  a  few  cases  of  long- 
standing perigastritis  due  to  disease  of  some  neighbouring  organ. 
Its  pathology  is  similar  to   that  form  of   endarteritis  which 
commonly  accompanies  cirrhosis  of  the  lung  and  kidney,  and 
in  the  case  of  a  gastric  ulcer  its  existence  is  of  some  value  to 
the  organism,  since  the  gradual  occlusion  of  the  arteries  which 
lie  in  the    track    of   the    advancing    disease   tends  to  prevent 
haemorrhage.     Syphilitic   endarteritis,  on    the    other   hand,  is 
comparatively  rare  as  a  primary  complaint,  and,  as  far  as  our 
experience   goes,  is    always   associated  with  gummata  in  the 
liver,  spleen,  pancreas,  or  retro-peritoneal    glands.     It  chiefly 
affects  the  smaller  branches  of  the  pyloric  vessels  which  ramify 
in  the  subserous  and  submucous  connective  tissue,  and  by  thus 
diminishing   the    blood-supply   to    the    part    tends   to    induce 
inflammatory  thickening  of  the  mucous  membrane  and  to  give 
rise  to    interstitial   haemorrhages    and    superficial  ulcerations. 
When  the  arterial  disease  is  especially  severe  or  widely  diffused, 
the  nutrition  of  the  gastric  wall  is  so  much  reduced  that  the 
tissues  are  no  longer  capable  of  withstanding  the  solvent  action 
of  the  gastric  secretion,  which  consequently  erodes  the  surface 
and  gradually  produces  an  indolent  form  of  ulceration.     In 
other  cases  the  partially  obstructed  vessel  becomes  the  seat  of 
thrombosis,  and  the  mucous  membrane  which  it  supplies,  being 
suddenly  deprived  of  blood,  is  rapidly  digested.     In  the  former 
case  the  patient  suffers  from  the  symptoms  of  chronic  ulcer  of 
the  stomach  ;    in  the  latter,  from  attacks  of  acute  dyspepsia, 
which  are  not  infrequently  followed  by  hasmatemesis. 

(3)  Chronic  Gastritis. — This  may  ensue  either  as  a  direct 
or  as  an  indirect  result  of  syphilis.  The  latter  variety  is  by 
far  the  more  common,  and  is  due  either  to  embarrassment 
of  the  gastric  circulation  from  disease  of  the  liver  or  spleen, 
to  lardaceous  degeneration  of  the  vessels  of   the  stomach,  to 


SYPHILIS  OF  THE   STOMACH  315 

secondary  disease  of  the  kidneys,  or  to  the  specific  cachexia. 
This  gastritis  does  not  differ  histologically  from  the  ordinary 
varieties,  and,  like  them,  usually  subsides  when  its  exciting  cause 
has  been  removed.  Chronic  inflammation  of  the  stomach  directly 
dependent  upon  the  systemic  infection  occasionally  results 
from  repeated  attacks  of  an  acute  character  during  the  early 
phases  of  the  complaint,  such  as  have  been  described  by  Jullien 
and  Fournier ;  but  as  a  rule  it  appears  only  at  an  advanced 
stage  of  the  disease,  and  is  often  associated  with  gummatous 
lesions  of  the  bones,  liver,  or  testes.  To  the  naked  eye  the 
mucous  membrane  either  is  dull  white  and  peculiarly  opaque, 
or  appears  to  be  thickened  and  irregularly  congested,  with  a 
surface  like  velvet  pile.  On  microscopical  examination  the 
superficial  roughness  of  the  tissue  is  found  to  be  due  to  an 
absence  of  the  normal  columnar  epithelium  and  to  a  hyperplasia 
of  the  connective  tissue  between  the  mouths  of  the  glands, 
which  give  the  section  the  appearance  of  being  covered  with 
fine  papillae.  The  capillary  vessels  which  ramify  between  the 
glands  are  dilated  and  filled  with  corpuscles ;  but  here  and 
there  their  outlines  are  obscured  by  an  accumulation  of  the  small 
round  cells,  which  pervade  the  whole  of  the  connective  tissue 
and  form  thick  layers  around  the  mouths  and  fundi  of  the 
glands.  The  lymphoid  follicles  are  enormously  enlarged,  and 
their  cellular  elements  frequently  penetrate  the  muscularis 
mucosas  and  invade  the  submucosa.  The  gastric  glands  vary 
in  appearance  at  different  parts  of  the  section,  at  one  spot  being 
comparatively  healthy,  while  at  another  they  are  twisted, 
distorted,  or  disorganised  by  the  round-cell  infiltration.  These 
general  features  are  common  to  all  forms  of  interstitial  gastritis, 
from  whatever  cause  they  arise,  but  in  the  present  case 
two  special  phenomena  exist  which  indicate  the  syphilitic 
origin  of  the  disease.  The  first  of  these  takes  the  form  of 
miliary  granulations,  which  occupy  the  whole  thickness  of  the 
mucosa  and  may  even  invade  the  submucous  tissue  or  project 
slightly  above  the  free  surface.  These  nodules,  which  are 
really  minute  gummata,  consist  for  the  most  part  of  a  homo- 
geneous granular  non-staining  material,  and  where  several 
have  coalesced  a  large  portion  of  the  section  may  consist 
entirely  of  this  cheesy  material.  The  other  characteristic 
feature  of  a  syphilitic  gastritis  is  a  hyperplasia  of  the  inner  coats 
of  the  small  arterioles  situated  in  the  submucosa,  which  pro- 


316  TUMOUKS   OF  THE   STOMACH 

duces  considerable  narrowing  of  their  lumina  and  not  infre- 
quently leads  to  thrombosis.  These  arterial  changes  may  be 
observed  in  any  part  of  the  section,  but  are  always  most 
noticeable  in  the  vicinity  of  the  miliary  gummata. 

Symptomatology. — Chronic  ulceration  of  the  stomach 
due  to  syphilis  is  most  common  in  men  between  twenty-five 
and  forty  years  of  age,  in  many  of  whom  secondary  symptoms 
of  the  infective  disorder  either  have  been  very  slight  or  were 
rapidly  removed  by  treatment.  The  gastric  complaint  usually 
develops  slowly,  and  for  several  months  may  be  mistaken  for 
some  form  of  simple  or  inflammatory  dyspepsia ;  but  sooner  or 
later  the  characteristic  symptoms  of  ulcer  show  themselves  and 
soon  become  severe.  So  far  as  our  own  experience  goes, 
these  cases  chiefly  differ  from  the  simple  variety  of  the  disease 
in  three  particulars,  the  first  of  which  is  the  extreme  severity 
of  the  pain  and  vomiting,  the  second  the  infrequency  of 
hemorrhage,  and  the  third  their  obstinacy  to  ordinary  treat- 
ment and  their  great  tendency  to  relapse. 

Pain  is  invariably  present,  and,  as  is  usual  in  gastric  ulcer, 
is  principally  experienced  in  the  epigastrium  within  half  an 
hour  after  a  meal  containing  solid  food.  In  many  instances, 
however,  the  suffering  is  almost  constant,  and  even  a  diet  of 
milk  gives  rise  to  oppression  at  the  chest  with  distension  and 
troublesome  flatulence.  When  the  disease  has  existed  for 
some  months  the  pain  is  often  most  intense  during  the  night, 
when  the  stomach  is  devoid  of  food,  and  it  may  then  extend 
all  over  the  abdomen  and  chest  and  radiate  down  the 
extremities  or  up  into  the  neck.  Under  these  conditions  the 
epigastrium  is  usually  very  tender,  and  the  cranium,  the  tibia3, 
and  the  heels  may  also  be  unduly  sensitive  to  pressure.  The 
attacks  last  for  several  hours,  and  are  frequently  accompanied 
by  flatulent  and  acid  eructations,  burning  in  the  throat,  intense 
thirst,  and  vomiting.  They  are  temporarily  relieved  by  a 
draught  of  milk  or  a  dose  of  bicarbonate  of  sodium,  and  more 
effectually  by  vomiting.  Kosanow  diagnosed  a  syphilitic  ulcer 
in  one  patient  on  account  of  the  nocturnal  pain,  and  successfully 
treated  it,  while  Bartumeus  appears  to  lay  stress  upon  attacks 
of  emesis  during  the  night ;  but  since  both  these  phenomena 
are  met  with  in  simple  ulcer  when  complicated  with  hyper- 
secretion, they  cannot  be  regarded  as  pathognomonic  of  the 
specific  form    of   the   complaint.     Vomiting   is   another   con- 


SYPHILIS   OF  THE   STOMACH  317 

spicuous  feature  of  the  disease.  At  first  the  patient  may  be 
sick  only  during  the  painful  crisis,  which  the  act  of  emesis 
tends  to  curtail ;  but  as  soon  as  secondary  gastritis  develops 
vomiting  may  occur  after  every  meal,  while  from  time  to  time 
attacks  come  on  which  last  for  many  days  and  prevent  the 
administration  of  nourishment  by  the  mouth.  The  constant 
pain  and  vomiting  soon  induce  a  serious  deterioration  of  the 
general  health.  The  patient  becomes  very  thin  and  feeble,  and 
presents  the  pinched  and  careworn  look  of  one  who  is  always 
suffering.  The  appetite  may  remain  good,  or  even  be  excessive, 
but  he  is  afraid  to  gratify  the  desire  for  food  on  account  of 
the  punishment  which  is  sure  to  follow  ;  while  at  intervals 
he  is  tormented  by  a  thirst  which  no  amount  of  water  will 
subdue.  The  bowels  are  confined  and  the  tongue  is  often 
covered  with  a  white  fur.  The  urine  is  diminished  in  amount 
and  its  reaction  is  often  neutral  or  slightly  alkaline,  while  in 
many  cases  it  contains  an  excess  of  phosphates  but  is  deficient 
in  chlorides.  Anaemia  is  invariably  present,  and  the  peculiar 
sallow  complexion  of  many  of  the  patients  is  very  suggestive 
of  a  specific  cachexia.  Although  nearly  70  per  cent,  of  the  cases 
of  simple  ulcer  suffer  from  hsernateniesis,  this  symptom  appears 
to  be  comparatively  rare  in  the  syphilitic  disease,  possibly  on 
account  of  the  gradual  obliteration  of  the  gastric  vessels,  which, 
as  has  already  been  pointed  out,  occurs  in  the  vicinity  of  the 
sore.  When,  however,  the  portal  circulation  is  embarrassed 
by  coexisting  disease  of  the  liver  or  spleen,  vomiting  of  blood 
may  be  an  early  and  recurrent  symptom. 

As  a  rule  the  complaint  fails  to  respond  to  the  ordinary 
methods  of  treatment,  and  even  when  anti-syphilitic  remedies 
are  employed  it  may  exhibit  a  great  tendency  to  relapse.  This 
latter  peculiarity  was  very  marked  in  the  case  of  a  woman  who 
came  under  our  care  four  or  five  times  within  two  years  for 
severe  pain  and  vomiting  after  meals,  accompanied  by  rapid 
emaciation.  On  each  occasion  the  administration  of  mercury 
and  iodides  afforded  almost  immediate  relief,  and  the  disease 
appeared  to  be  cured  at  the  end  of  two  months  ;  but  as  soon  as 
she  discontinued  the  medicine,  though  persevering  with  a  liquid 
diet,  the  pain  recurred  and  she  again  lost  flesh  and  vomited  her 
food. 

With  regard  to  the  chemistry  of  digestion  there  is  very 
little  evidence  to  offer.     In  the  early  stages  of  the  complaint 


318  TUMOUES  OF  THE   STOMACH 

free  hydrochloric  acid  may  usually  be  detected  after  a  test 
meal,  and  in  those  cases  where  nocturnal  attacks  of  pain  are 
present  the  vomit  usually  contains  an  excess  of  the  mineral 
acid.  But  when  the  disease  has  given  rise  to  great  loss  of  flesh 
and  to  debility  we  have  never  observed  hyperchloracidity,  but, 
on  the  contrary,  have  often  found  evidence  of  lactic  acid 
fermentation.  When  vomiting  is  excessive  the  ejecta  consist 
almost  entirely  of  alkaline  and  bile-stained  mucus.  The  usual 
cause  of  death  is  exhaustion  from  inanition,  but  an  intercurrent 
affection  like  tuberculosis  or  some  syphilitic  complication  often 
hastens  the  fatal  termination.  Hseniateniesis  and  perforation 
appear  to  be  rare.  Among  the  sequelas  of  the  disease,  pyloric 
stenosis  is  the  most  important,  and  has  been  recorded  by  Cornil, 
Wagner,  and  Klebs. 

Gastritis  occurs  both  in  hereditary  and  acquired  syphilis, 
and  is  chiefly  characterised  by  its  chronicity  and  intractability 
to  ordinary  treatment.  In  infancy  and  early  childhood  the 
intestine  usually  suffers  along  with  the  stomach,  so  that  in 
addition  to  the  vomiting  there  is  either  diarrhoea  or  obstinate 
constipation.  In  all  cases  the  loss  of  flesh,  anaemia,  and 
debility  are  out  of  proportion  to  the  severity  of  the  local 
symptoms,  owing  to  the  consecutive  atrophy  of  the  gastric  and 
intestinal  glands,  which  can  be  demonstrated  in  almost  every 
case  of  so-called  '  syphilitic  marasmus.'  During  the  period  of 
childhood  intercurrent  attacks  of  acute  gastritis,  characterised 
by  incessant  nausea  and  vomiting,  and  occasionally  by  severe 
gastralgia,  are  apt  to  occur  from  time  to  time.  The  bowels  are 
confined,  the  tongue  is  thickly  coated,  and  slight  delirium  may 
appear  at  night.  If  no  food  can  be  retained  in  the  stomach 
the  disease  may  prove  fatal ;  but  as  a  rule  the  acute  disease 
passes  off  in  a  few  days,  and  is  again  replaced  by  the  chronic 
form.  In  almost  every  instance  the  child  presents  evidences  of 
syphilis  in  the  face,  teeth,  and  eyes,  while  not  infrequently  the 
development  of  a  gumma  heralds  the  onset  of  an  acute  attack. 
In  one  case  which  came  under  our  ca^re  a  large  mass  could  be 
felt  for  several  months  in  the  liver,  and  subsequently  a  gum- 
matous swelling  appeared  upon  the  forehead;  while  in  one 
reported  by  Hemmeter  the  child  presented  an  enormous  gumma 
of  the  lower  jaw. 

Mild  forms  of  syphilitic  gastritis  occurring  in  adult  life  are 
practically  indistinguishable  from  the  alcoholic  variety,  while  in 


SYPHILIS   OF  THE   STOMACH  319 

the  more  severe  cases  the  progressive  loss  of  flesh,  excessive 
debility,  anorexia,  and  profound  anaemia,  coupled  with  an  absence 
of  free  hydrochloric  acid  from  the  gastric  contents,  are  highly 
suggestive  of  a  malignant  growth.  More  than  one  case  of  this 
description  has  come  under  our  care  in  which,  if  it  had  not 
been  for  the  routine  trial  of  iodide  of  potassium,  we  should  have 
diagnosed  cancer  of  the  stomach  ;  and  we  have  known  several 
patients,  who  were  condemned  to  carcinoma  of  the  stomach  or 
pancreas  after  an  exploratory  incision,  who  made  a  perfect 
recovery  under  anti-syphilitic  treatment.  Although  traces  of 
altered  blood  maj7  appear  in  the  vomit,  severe  haematemesis  is 
rarely  observed,  unless  the  liver  or  spleen  is  also  diseased. 

Diagnosis. — In  the  diagnosis  of  syphilitic  ulcer  of  the 
stomach  two  elementary  principles  should  always  be  kept 
prominently  in  mind.  In  the  first  place,  every  gastric  ulcer  is 
not  due  to  syphilis  simply  because  the  patient  happens  to  have 
suffered  at  one  time  or  other  from  that  complaint.  It  must 
be  remembered  that  probably  about  5  per  cent,  of  the  popula- 
tion suffer  from  ulcer  at  some  period  of  their  existence,  and, 
since  syphilis  is  also  by  no  means  uncommon,  it  must  necessarily 
happen  that  the  twTo  diseases  will  frequently  be  associated  in 
the  same  individual,  independently  of  any  causal  relationship 
between  them.  In  308  cases  of  chronic  gastric  ulcer  of  which 
we  possess  clinical  notes  a  history  of  former  syphilis  existed  in 
10  per  cent.  ;  but  in  132  cases  of  the  disease  which  proved 
fatal,  gummata  or  other  evidences  of  syphilis  were  only  observed 
after  death  in  eight,  or  6  per  cent.  We  are,  therefore,  of 
opinion  that  only  about  5  per  cent,  of  all  chronic  ulcers  of  the 
stomach  have  any  direct  connection  with  syphilis,  and  that  in 
the  majority  of  these  the  connecting-link  is  to  be  found  in 
arterial  degeneration  rather  than  in  the  formation  of  gummata. 

The  second  point  is  this.  Before  it  is  accepted  that  the 
symptoms  of  gastric  irritation  in  a  syphilitic  subject  are  due  to 
the  specific  malady  it  must  be  clearly  ascertained  that  they  do 
not  arise  from  injudicious  medication.  Many  persons  are  very  in- 
tolerant both  of  mercury  and  potassium  iodide,  and  the  prolonged 
administration  of  these  drugs  frequently  gives  rise  to  trouble- 
some gastritis,  accompanied  by  anaemia,  loss  of  appetite,  emacia- 
tion, and  great  debility.  When  these  symptoms  develop  in  a 
patient  who  has  been  under  observation  from  the  first,  there  is, 
of  course,  no  difficulty  in  assigning  the  gastric,  disorder  to  its 


320  TUMOUES   OF  THE   STOMACH 

proper  cause,  and  in  curing  it  by  discontinuing  the  treatment. 
When,  however,  a  patient  of  whom  nothing  is  known,  except 
that  he  has  had  syphilis,  seeks  advice  on  account  of  chronic 
gastritis,  there  is  always  a  great  temptation  to  overlook  the 
possibility  of  toxic  influences  and  to  prescribe  the  same  drugs 
which  were  originally  responsible  for  the  disease.  A  good 
instance  of  this  recently  came  under  our  notice  in  the  case  of  a 
woman  who  was  sent  to  us  with  a  diagnosis  of  cancer  of  the 
stomach  on  account  of  the  pain  after  food,  vomiting,  and  loss 
of  flesh  from  which  she  had  suffered  for  several  months.  We 
found  upon  inquiry  that  she  had  been  under  medical  treatment 
for  some  time  for  an  ulcer  of  the  leg,  and  was  inclined  to 
attribute  her  indigestion  to  the  pain  and  worry  attendant  upon 
that  disease.  As,  however,  she  was  obviously  suffering  from  a 
gastritis  of  toxic  origin,  we  preferred  to  take  the  view  that  the 
medicine,  and  not  the  sore  on  the  leg,  was  the  cause  of  the 
trouble,  the  assumption  being  that  the  former  treatment  had 
been  directed  against  possible  syphilis.  Careful  regulation  of 
diet,  combined  with  a  rhubarb  and  bismuth  mixture,  afforded 
immediate  relief,  and  within  a  month  the  patient  reported  herself 
as  feeling  perfectly  well.  It  is  therefore  important  to  remember 
that  gastritis  occurring  during  the  course  of  syphilis  may  result 
from  injudicious  treatment  as  well  as  from  the  disease  itself. 

Specific  ulceration  of  the  stomach  has  chiefly  to  be  distin- 
guished from  the  simple  variety,  from  carcinoma,  and  from 
the  gastric  crises  of  locomotor  ataxia.  In  every  case  of  gastric 
ulcer  the  possibility  of  former  syphilis  should  be  borne  in  mind, 
and  a  search  should  be  made  for  scars  and  other  evidences  of 
the  disease.  Excessive  pain  and  vomiting,  with  great  emacia- 
tion or  profound  anaemia,  are  always  suspicious  symptoms, 
while  nocturnal  attacks  in  which  pain  is  felt  in  the  long  bones 
as  well  as  in  the  abdomen  are  also  suggestive  of  syphilis.  The 
chief  point  of  distinction,  however,  is  the  intractability  of 
the  disease  to  ordinary  methods  of  treatment,  while  its  sym- 
ptoms rapidly  subside  on  the  administration  of  anti-syphilitic 
remedies.  More  than  sixty  years  ago  Andral  diagnosed  a 
syphilitic  ulcer  of  the  stomach  from  the  fact  that  it  was  cured 
by  the  administration  of  mercury,  and  Galliard,  Lancereaux, 
Wagner,  Hayem,  Kosanow,  and  Marc  have  all  recorded  instances 
in  which  the  nature  of  the  complaint  was  manifested  in  a 
similar  manner, 


SYPHILIS   OF  THE   STOMACH  321 

The  differential  diagnosis  of  specific  nicer  and  cancer  is 
often  very  difficult,  especially  when  the  former  is  accompanied  by 
severe  gastritis.  In  malignant  disease,  however,  a  tumour  can 
usually  be  detected  in  connection  with  the  stomach,  the  loss  of 
flesh  and  strength  is  more  rapid,  nocturnal  attacks  of  pain  are 
infrequent,  and  the  vomit  often  contains  altered  blood.  The 
subjects  of  gastric  cancer  are  also  very  intolerant  of  mercury  and 
iodides,  and  after  a  few  days'  treatment  with  these  drugs  will 
usually  volunteer  the  statement  that  the  medicine  is  making 
them  much  worse.  In  the  syphilitic  affection,  on  the  other 
hand,  these  remedies  are  the  only  ones  which  are  found  to  afford 
relief. 

The  gastric  crises  of  tabes  occur  at  irregular  intervals,  and 
are  seldom  excited  by  the  ingestion  of  food.  There  is  little  or 
no  localised  tenderness  of  the  epigastrium,  and  the  patient 
presents  the  usual  signs  of  early  ataxia.  It  is  important  to 
remember  that  syphilitic  lesions  of  the  central  nervous  system 
and  of  the  stomach  seldom,  if  ever,  develop  in  the  same 
individual. 

The  diagnosis  of  syphilitic  gastritis  is  made  by  the  absence 
of  the  usual  conditions  which  excite  inflammation  of  the 
stomach  and  by  the  discovery  of  a  history  or  objective  signs 
of  syphilis.  A  few  days'  trial  of  iodide  of  potassium  will 
usually  suffice  to  clear  up  any  doubt,  since  in  ordinary  cases  of 
gastritis  this  drug  greatly  increases  the  dyspeptic  symptoms, 
while. the  contrary  result  is  observed  in  the  specific  disorder. 

Treatment. — Absolute  rest  is  essential,  and  much  time  will 
be  saved  if  the  patient  is  confined  to  bed  for  the  first  fortnight. 
Milk  should  form  the  staple  diet  for  the  first  three  or  four 
weeks,  but  as  it  does  not  always  agree  so  well  as  in  simple 
ulcer  it  may  be  necessary  to  dilute  it  with  soda-water  or  Vichy 
water.  When  vomiting  is  a  troublesome  symptom  the  milk 
should  be  peptonised.  Clear  soups,  broths,  jellies,  and  junket 
may  also  be  allowed  if  the  patient  can  take  them  without  dis- 
comfort. After  the  first  month,  should  the  case  be  progressing 
favourably,  milk  puddings,  soft  bread  and  butter,  eggs,  tripe, 
and  oysters  may  be  permitted,  and  the  diet  may  subsequently 
be  increased  by  the  addition  of  pounded  fish,  finely  minced 
sweetbreads,  and  chicken  cream.  Meat  and  green  vegetables 
should  be  prohibited  for  at  least  six  months.  If  vomiting  is 
troublesome,  it  may  be  necessary  to  feed  the  patient  by  the 


322  TUMOUES   OF  THE   STOMACH 

rectum.  "When  abdominal  pain  is  severe  the  epigastrium 
may  be  constantly  covered  with  a  large  linseed  poultice,  but  as 
a  rule  the  repeated  application  of  a  small  blister  is  of  greater 
value.  With  regard  to  medicinal  treatment,  it  may  be  stated  at 
once  that  mercury  should  always  be  combined  with  an  iodide, 
since  the  latter  is  much  less  efficacious  when  given  alone.  In 
most  instances  it  is  sufficient  to  prescribe  a  mercurial  pill  of 
two  grains,  with  an  equal  quantity  of  extract  of  hyoscyamus, 
night  and  morning,  but  in  some  cases  drachm  doses  of  the 
solution  of  perchloride  of  mercury  are  to  be  preferred.  In 
young  children  inunctions  of  mercurial  ointment  or  full  doses 
of  mercury  and  chalk  are  the  most  convenient  methods  of 
administering  the  drug.  If  there  is  any  tendency  to  diarrhoea 
a  small  quantity  of  opium  may  be  included  in  the  prescription. 
The  iodide  of  potassium  or  of  sodium  must  be  given  in  doses 
of  from  five  to  fifteen  grains,  and  is  most  conveniently  com- 
bined with  carbonate  of  bismuth  and  liquid  extract  of  sarsa- 
parilla  ;  while  the  addition  of  ten  minims  of  glycerine  of  carbolic 
acid  often  tends  to  relieve  the  oppression  and  flatulence  which  are 
experienced  after  meals.  Should  the  bowels  remain  constipated 
in  spite  of  the  mercurial,  a  teaspoonful  or  more  of  the  artificial 
Carlsbad  salts  may  be  given  each  morning  before  breakfast. 
Lavage  is  chiefly  indicated  in  the  cases  of  chronic  gastritis 
accompanied  by  troublesome  vomiting,  or  where  an  ulcer  has 
caused  partial  obstruction  of  the  pylorus,  but  it  should  be 
avoided  when  symptoms  of  active  ulceration  are  present.  In 
every  instance  the  patient  should  be  warned  of  the  tendency  of 
the  disease  to  relapse,  lest  he  be  tempted  to  discontinue  the 
treatment  as  soon  as  the  urgent  symptoms  have  subsided. 


BIBLIOGBAPHY 

Andral,  Clinique  Med.,  tome  iv.  p.  121. 

Bartumens,  Eevista  cle  Ciencias  Med.,  Barcelona,  1879,  p.  348. 

Berthold,  Statistischer  Beitrag   zur  Kenntnis  des  chronischen  Magengeschwiirs. 

Inaug.  Dissert.,  Berlin  1883. 
Birch-Hirschfcld,  Lehrb.  der  pathol.  Anat.,  1885,  ii.  p.  531. 
Bittner,  Centraibl.  f.  allgem.  Pathol.,  1894,  p.  175. 
Capozzi,  Schmidt's  Jahrb.,  vol.  cxxxv.  p.  41. 
Chiari,  International-Beitrag  z.  Wissenschaft :  Medicin  Budolf  Virchow,  gewidmet 

1891,  ii. 
Comil,  Manuel  de  l'Histolog.  Patholog.,  1882,  ii.  p.  296. 
Fauvel,  Bull.  Soc.  Anat.,  1858,  p.  224. 


SYPHILIS   OF  THE   STOMACH  323 

Fenwick,  Soltau,  Lancet,  1901,  ii.  p.  835. 

Foumier,  Gaz.  Hebdom.  de  Med.  et  de  Chirurg.,  1871,  1  and  2. 

Galliard,  Arch.  G6nerales  de  Medecine,  1886,  p.  66. 

Hayem  et  Tissier,  Kevue  de  M6d.,  1889,  p.  231. 

Hemmeter,  Diseases  of  the  Stomach,  p.  554. 

Hiller,  Monatshefte  f.  prakt.  Dermatologie,  1882,  i.  p.  97. 

Jahresbericht  der  k.  k.  Krankenanstalt  Eudolf-Stiftung,  1883,  p.  383. 

Jullien,  Traite  Pratique  des  Malad.  Vener.,  1879,  p.  615. 

Klebs,  Pathologische  Anatomie,  1869,  i.  p.  262. 

Lancereaux,  Traite  Historique  et  Pratique  de  la  Syphilis,  1873,  p.  249. 

Lang,  Wien.  nied.  Presse,  1885,  p.  43. 

Neumann,  '  Syphilis,'  Nothnagel's  spec.  Pathol,  u.  Therap.,  xxiii.  p.  351. 

Nolte,  Ueber  die  Haufigkeit  des  Magengeschwiirs  in  Munchen.     Inaug.  Dissert. 

1883. 
Orth,  Lehrbuch  d.  speciellen  pathol.  Anat.,  1887,  i.  p.  717. 
Oser,  Vierteljahrsch.  fiir  Dermatologie  u.  Syphilis,  1871,  p.  27. 
Rosanoio,  La  Semaine  Medicale,  1890,  p.  368. 
Tiillio,  Policlinica,  xv.,  Giugni,  1894. 
Virchoiv,  Handbuch  der  spec.  Path.  u.  Ther.,  i.  p.  71. 
Wagner,  Archiv  der  Heilkunde,  1863,  iv.  pp.  225,  369. 
Weichselbaum,  Bericht  d.  Eudolfspitals  in  Wien,  1883,  p.  383. 
Zawaclski  &  Luxembourg,  Gaz.  Lekarska,  1893,  xiii.  p.  1233. 


y  2 


324  TUMOUES  OF  THE   STOMACH 


CHAPTEE  V 

CONGBETIONS  IN  THE   STOMACH 
[Hair-balls — Bezoars — Gastroliths] 

Ceetain  concretions  are  apt  to  form  in  the  stomach,  and  to 
give  rise  to  severe  gastric  symptoms  attended  by  an  abdominal 
tnmour.  As  a  rule  they  consist  of  hair,  cotton,  wool,  tow  or 
string,  but  occasionally  they  are  composed  entirely  of  vegetable 
matter,  fibrous  roots,  or  of  resinous  material. 

(1)  Hair-balls  of  sufficient  size  to  attract  attention  are  very 
rare,  and  we  have  beena  ble  to  collect  only  twenty-four  cases, 
the  first  of  which  was  recorded  by  Baudamant  in  1777. l 
When  comparatively  small  the  mass  is  round  or  oval  in  shape, 
and  occupies  the  pyloric  region,  where  it  acts  like  a  ball-valve ; 
but  as  it  increases  in  size  it  becomes  moulded  by  the  gastric 
contractions,  until  it  forms  a  solid  cast  of  the  organ,  and  may 
even  extend  upwards  into  the  oesophagus  (Best)  or  through 
the  pylorus  into  the  jejunum  (Gull,  Pollock).  It  is  smooth 
on  the  surface,  compact  and  heavy,  and  consists  of  a  vast 
number  of  hairs,  varying  from  two  to  twelve  inches  in  length, 
which  are  closely  interwoven  and  agglutinated  by  mucus  and 
food  debris.  In  Gull's  case  the  component  hairs  were  of  three 
colours,  and  could  be  recognised  as  belonging  to  the  patient 
and  her  two  children.  Sometimes  the  hair  is  mixed  with 
cotton,  thread,  or  pieces  of  string.  The  largest  concretion  on 
record  weighed  41b.  7  oz.  (Eussell),  and  the  smallest  5|  oz. 
The  habit  of  swallowing  hair  is  not  confined  to  the  human 
subject,  but  is  met  with  in  the  lower  animals,  and  especially  in 
cats,  the  Angora  breed  of  which  are  said  frequently  to  die  from 
gastric  concretions,  owing  to  their  habit  of  eating  their  fur  when 
it  is  shed  at  certain  periods  of  the  year  (Chepmell).     Lunatics 

1  Schonborn  states  that  in  the  year  1883  only  seven  cases  had  been  recorded. 
He  appears,  however,  to  have  overlooked  English  and  American  literature. 


CONCEETIONS   IN  THE   STOMACH  325 

usually  prefer  harder  substances,  such  as  nails  and  crockery, 
but  in  a  case  recorded  by  Quain  fatal  perforation  of  the 
stomach  was  caused  by  a  ball  of  cocoanut  fibre  weighing  four 
pounds. 

(2)  Concretions  composed  of  vegetable  matter  are  occa- 
sionally found  in  the  stomachs  of  persons  who  have  consumed 
large  quantities  of  fibrous  roots  or  of  other  substances,  owing 
to  a  perverted  appetite  or  from  a  superstitious  belief  in  their 
medicinal  properties.  Thus,  in  Kooyker's  case  a  mass  of  starch 
and  vegetable  fibre  weighing  twenty-nine  ounces  was  found 
in  the  stomach  after  death  ;  while  in  that  recorded  by  Schreiber 


Fig.  64 A  hair-ball  (about  one-half  natural  size). 

the  organ  was  completely  filled  by  a  mass  of  roots  (Schwarz- 
wurzel) . 

(3)  Stones  or  Gastroliths  are  very  rare,  and  we  have  been 
able  to  find  only  four  authentic  case*  in  the  literature.  They 
usually  consist  of  shellac,  which  has  been  introduced  into  the 
stomach  in  the  form  of  an  alcoholic  polish  or  varnish,  and 
may  be  either  single  or  multiple  (Friedlander).  As  a  rule  they 
do  not  exceed  three  ounces  in  weight,  but  in  the  case  related 
by  Tidemand  the  mass  weighed  1,500  grammes. 

The  local  effects  of  the  concretion  consist  of  dilatation  of  the 
stomach  with  chronic  inflammation  and  atrophy  of  its  mucous 
membrane;  while  occasionally  the  organ  becomes  fixed  by 
adhesions  to  the  pancreas  or  abdominal  wall  (May).  When 
the  oesophagus  or  the  duodenum  is  involved  the  orifices  may  be 


326  TUMOUES   OF  THE   STOMACH 

greatly  dilated.  In  more  than  one-half  of  the  cases  death 
occurred  from  perforation  of  the  stomach  in  the  pyloric  region, 
or,  as  in  those  related  by  Gull  and  Yeo,  from  a  similar  lesion  of 
the  duodenum.  Hseniatemesis  was  responsible  for  the  fatal 
termination  in  one  instance  (Russell),  and  intestinal  obstruction 
in  several  others  (Ritchie,  Friedlander).  Occasionally  the 
chronic  irritation  of  the  mass  gives  rise  to  superficial  erosions, 
or  even  to  papillomata  (Best). 

Symptoms. — The  fact  that  various  foreign  bodies  are  fre- 
quently found  in  the  alimentary  tract  of  lunatics  has  given 
rise  to  the  impression  that  gastric  concretions  occur  only  hi 
persons  of  unsound  mind.  This  belief  is  not  only  erroneous, 
but  has  been  the  cause  of  serious  mistakes  in  diagnosis,  for 
more  than  one  writer  has  stated  that,  had  he  been  aware  that 
sane  people  were  liable  to  the  complaint,  he  might  have 
suspected  the  nature  of  the  abdominal  tumour  and  have  saved 
the  patient's  life  by  a  timely  operation. 

(1)  Hair-balls.- — Out  of  the  twenty-four  cases  of  this  variety 
no  fewer  than  twenty-three  wTere  females,  the  }Toungest  of 
whom  was  eighteen 1  and  the  oldest  thirty-four  at  the  time  of 
death.  There  were  never  any  indications  of  mental  disease, 
and  in  several  instances  it  was  expressly  mentioned  that  the 
patient  was  neither  hysterical  nor  particularly  emotional. 

The  habit  of  hair-swallowing  is  usually  acquired  in  early 
life,  when  the  hair  is  worn  loose  upon  the  shoulders.  In  the 
majority  of  cases  it  originates  in  the  trick  frequently  practised 
by  young  girls  of  holding  a  lock  of  hair  in  the  mouth  while 
reading  a  book,  or  of  biting  the  ends  of  a  coil  when  angry  or 
excited.  In  other  instances  it  seems  to  arise  from  the  inclination, 
which  is  so  strongly  marked  in  certain  people,  to  fill  the  mouth 
with  any  substance  with  which  they  happen  to  be  working,  such 
as  cotton  in  the  case  of  dressmakers,  wool  or  thread  among 
weavers,  and  tow,  flock,  or  cocoanut-fibre  among  those  engaged 
in  the  manufacture  of  mattresses  or  mats.  Finally,  it  may 
be  due  to  some  acquired  eccentricity,  of  which  the  patient  her- 
self is  often  quite  unconscious.  Thus,  in  one  case  the  husband 
stated  that  whenever  his  wife  was  unusually  interested  in  a 
subject  she  invariably  pulled  out  two  or  three  hairs  from  the 
back  of   her  head  and  put   them    into    her  mouth  ;    while  in 

1  Since  this  chapter  was  written  Paton  has  reported  the  successful  removal  of 
a  hair-ball  from  the  stomach  of  a  girl  eight  years  of  age. 


CONCEETIONS  IN  THE   STOMACH  327 

another  it  was  observed  that  the  lady  would  frequently  pluck 
hairs  from  her  children's  heads  when  she  caressed  them  or 
played  with  them.  In  the  instance  recorded  by  Inman  the 
patient  was  accustomed  to  clean  her  comb  with  her  fingers,  and 
quite  unwittingly  to  put  the  little  bunch  of  loose  hair  into  her 
mouth  instead  of  into  a  toilet  tidy.  In  each  of  these  conditions 
it  is  probable  that  the  mouth  and  throat  become  so  tolerant  of 
the  presence  of  the  foreign  substance  that  the  hairs  are  con- 
stantly swallowed  with  the  saliva  without  creating  any 
unpleasant  symptoms. 

Until  the  concretion  has  attained  a  considerable  size  and 
has  seriously  diminished  the  capacity  of  the  stomach  it  seldom 
produces  any  special  symptoms,  and  even  when  the  organ  is 
completely  filled  with  hair  the  patient  may  be  quite  free  from 
pain  and  vomiting  (Eussell,  Thornton).  As  a  rule,  however, 
after  a  prolonged  period  of  more  or  less  pronounced  dyspepsia 
the  patient  begins  to  experience  severe  pain  after  meals  with 
flatulence,  distension,  and  nausea.  Gradually  the  pain  becomes 
localised  to  the  epigastrium  or  left  hypochondrium,  and  is 
increased  by  exercise  or  pressure  upon  the  part.  Vomiting  is 
seldom  absent,  and  sometimes  occurs  after  every  meal.  The 
ejecta  are  small  in  quantity,  acid  in  reaction,  and  often  contain 
altered  bile  if  the  concretion  involves  the  duodenum.  Occasion- 
ally the  vomit  is  stained  with  blood  ;  but  hair  has  never  been 
observed  in  it.  Anseinia  is  always  a  noticeable  feature  of  the 
case,  and  may  be  accompanied  by  palpitation,  dyspnoea,  and 
oedema  of  the  feet.  The  appetite  is  variable,  but  sometimes 
continues  good  ;  the  tongue  is  foul,  the  breath  offensive,  and 
attacks  of  diarrhoea  are  apt  to  alternate  with  periods  of  trouble- 
some constipation.  Progressive  loss  of  flesh  is  seldom  observed 
except  when  vomiting  is  excessive. 

Physical  Signs. — In  every  case  there  is  a  well-marked  ab- 
dominal tumour,  which  is  often  large  enough  to  be  visible  through 
the  parietes.  When  the  concretion  is  comparatively  small  the 
tumour  is  globular  in  form  and  occupies  the  epigastrium,  but 
in  advanced  cases  it  approximates  closely  to  the  shape  of  the 
stomach,  and  was  variously  described  in  the  recorded  cases  as 
'kidney-shaped,'  '  crescentic,'  or  '  like  a  spleen.'  As  a  rule  it  is 
situated  in  the  epigastrium  and  left  hypochondrium,  but  it  may 
involve  the  umbilical  and  the  left  lumbar  region.  In  Kussell's 
case  the  stomach  was  so  displaced  that  the  pylorus  lay  in  the 


328 


TUMOUES   OF   THE   STOMACH 


pelvis  and  the  tumour  occupied  the  whole  of  the  left  side  of 
the  abdomen. 

On  palpation  it  feels  hard,  smooth,  and  superficial,  and  has 
a  well-defined  lower  border.  It  is  dull  on  percussion  and 
seldom  tender,  except  after  prolonged  manipulation  and  in  those 
cases  where  the  stomach  is  ulcerated.  One  of  the  principal 
features  of  the  tumour  is  its  extreme  mobility,  which  permits 
it  to  be  displaced  downwards  and  to  the  left,  or  to  be  pushed 
upwards  beneath  the  costal  margin  in  the  direction  of  the 
spleen.  At  a  late  stage  of  the  complaint,  however,  adhesions 
may  form,  which  fix  the  organ  to  the  pancreas  or  abdominal  wall 


Fig. 


65. — Tumour  formed  by  a  hair- 
ball  in  the  stomach. 


Fig.  66. — Tumour  formed  by  a  large 
hair-ball  which  had  produced 
dislocation  of  the  stomach. 


(May).  Peristaltic  movements  of  the  stomach  are  rarely 
visible,  but  flatus  may  sometimes  be  seen  or  felt  in  the  tumour 
(Best).  Sometimes  other  hard,  globular,  and  movable  masses 
may  be  detected  to  the  right  of  the  navel  or  in  the  iliac  fossa 
from  the  presence  of  hair-balls  in  the  duodenum  or  ileum.  In 
every  case  the  tumour  enlarges  very  slowly,  and,  except  perhaps 
for  a  sensation  of  weight  or  dragging,  it  does  not  give  rise  to 
any  special  inconvenience. 

Duration  and  Complications. — The  duration  of  the  disease 
is  difficult  to  determine,  but  it  probably  averages  about  fifteen 
years.  In  May's  case  the  patient  was  known  to  have  practised 
hair-swallowing  for  twenty-two  years,  and  in  that  recorded  by 


CONCEETIONS  IN  THE   STOMACH  329 

Russell  the  tumour  had  been  detected  at  the  age  of  fourteen. 
From  its  slow  growth  during  adult  life  it  is  probable  that  the 
greater  part  of  the  concretion  is  formed  during  childhood.  With 
the  exception  of  two  instances  in  which  laparotomy  was  per- 
formed, all  the  cases  ended  fatally.  In  about  one  half  death  was 
due  to  ulceration  and  perforation  of  the  stomach ;  fatal  haemat- 
emesis  occurred  in  one  instance,  while  in  two  others  intestinal 
obstruction  was  responsible  for  the  lethal  event.  In  all  the 
rest  death  ensued  from  exhaustion  entailed  by  vomiting  and 
diarrhoea. 

Case  XXIX.  A  girl,  eighteen  years  of  age,  had  suffered  for  some 
time  from  pain  and  vomiting  after  food,  a  capricious  appetite,  and 
looseness  of  the  bowels.  In  the  epigastrium  there  was  a  tumour 
about  the  size  of  an  orange,  globular  in  shape,  somewhat  movable, 
and  of  very  slow  growth.  The  patient  suddenly  became  collapsed, 
and  died  of  peritonitis.  At  the  necropsy  the  stomach  was  found  to 
be  filled  by  a  mass  of  hair  and  string,  which  was  moulded  to  the 
shape  of  the  organ  and  measured  six  inches  long,  three  and  three- 
quarter  inches  in  width,  and  two  and  a  half  inches  in  thickness.  A 
second  cylindrical  mass  measuring  fourteen  inches  in  length  filled  the 
duodenum  and  extended  into  the  jejunum.  A  chronic  ulcer  of  the 
stomach  had  perforated  into  the  peritoneal  cavity. — Pollock. 

Case  XXX.  A  lady,  thirty-one  years  of  age,  was  suddenly  seized 
with  severe  hgematemesis.  She  had  not  suffered  from  any  gastric 
symptoms  previously,  but  was  known  to  have  had  an  abdominal 
tumour  since  the  age  of  fourteen.  The  tumour  now  occupied  the 
whole  of  the  left  side  of  the  abdomen  and  extended  from  beneath  the 
left  costal  margin  to  the  pelvis.  It  moved  with  respiration,  was  dull 
on  percussion,  and  had  a  hard  smooth  surface.  The  inner  border 
was  slightly  concave,  well  defined,  and  apparently  presented  a  notch 
about  its  centre.  It  resembled  a  spleen  in  every  particular,  with  the 
possible  exception  that  its  length  was  somewhat  out  of  proportion  to 
its  width.  The  haemorrhage  proved  fatal.  A  necropsy  showed  that 
the  tumour  was  composed  of  the  stomach,  which  was  almost  vertical 
in  position,  with  the  pylorus  in  the  cavity  of  the  pelvis.  Its  contents 
consisted  of  a  firm  mass  of  hair  measuring  twelve  inches  in  length, 
five  in  width,  and  four  in  thickness,  and  weighing  4  lb.  7  oz.  The 
individual  hairs  were  of  all  lengths  up  to  twenty  inches.  The 
mucous  membrane  near  the  great  curvature  was  ulcerated,  and  the 
pylorus  was  dilated  to  about  four  times  its  normal  size.  The  lady's 
husband  stated  that  whenever  his  wife  became  excited  she  was  in 
the  habit  of  pulling  two  or  three  hairs  from  her  head  and  putting 
them  into  her  mouth. — Russell. 


330  TUMOUES  OF  THE   STOMACH 

Case  XXXI.  A  factory-girl,  aged  twenty-one  years,  was  admitted 
into  hospital  with  the  symptoms  of  acute  intestinal  obstruction.  A 
large  movable  tumour  could  be  felt  in  the  epigastrium.  After  death 
the  stomach  was  found  to  contain  a  mass  of  hair  weighing  twenty- 
one  ounces,  which  had  produced  extensive  ulceration  of  the  viscus. 
The  ileum  was  ruptured  just  above  the  caecum,  and  on  either  side  of 
the  lesion  there  was  a  ball  of  hair,  the  larger  of  which  weighed  one 
and  a  half  ounces  and  had  obstructed  the  intestine  at  the  ileo-caBcal 
valve. — Bitchie. 

Case  XXXII.  A  girl  fifteen  years  of  age  came,  under  treatment  for 
an  abdominal  tumour.  For  three  years  she  had  suffered  from  severe 
pain  and  vomiting  after  food.  The  tumour,  which  occupied  the 
epigastrium  and  left  hypochondrium,  felt  like  a  large  kidney  with  the 
hilus  upwards  and  to  the  right.  It  was  hard,  freely  movable,  dull 
on  percussion,  and  somewhat  tender.  An  exploratory  operation 
proved  that  it  was  contained  in  the  stomach,  and  when  the  organ 
was  incised  a  large  mass  of  hair  was  found  and  removed.  After  the 
patient  had  recovered  it  was  ascertained  that  for  at  least  four  years 
she  had  been  accustomed  to  swallow  hair  in  order  to  improve  her 
voice. — Schonborn. 

(2)  Vegetable  Tumours. — These  are  even  rarer  than  the 
preceding,  and  consist  of  undigested  vegetable  material,  fruit 
skins,  cherry  stalks,  or  the  fibrous  roots  of  certain  plants 
which  had  been  swallowTed  on  account  of  their  reputed  medicinal 
virtues. 

Except  that  they  occur  at  a  somewhat  later  period  of 
life,  the  symptoms  are  similar  to  those  already  noted.  For 
several  years  there  is  complaint  of  pain  and  vomiting  after  food, 
with  loss  of  appetite,  emaciation,  and  an  irregular  action  of  the 
bowels.  Occasionally  hsematernesis  and  cachexia  are  also 
observed.  The  tumour  is  seldom  as  large  as  a  hair-ball,  and 
is  usually  globular  in  shape  and  situated  in  the  epigastrium.  As 
a  rule  death  ensues  from  perforation  of  the  stomach,  hasmorrh age, 
or  exhaustion,  but  occasionally  the  foreign  body  undergoes 
disintegration  and  is  either  vomited  or  evacuated  by  the  bowel. 

Case  XXXIII.  An  individual,  fifty-two  years  of  age,  came  under 
medical  treatment  for  severe  pain  and  vomiting  after  food,  with 
progressive  loss  of  flesh.  Haamatemesis  had  occurred  at  intervals, 
and  there  was  marked  cachexia.  In  the  epigastrium  a  round  tumour 
the  size  of  a  small  apple  could  be  felt,  which  was  dull  on  per- 
cussion, movable,  and  slightly  tender.  The  diagnosis  was  obscure, 
and   opinions   varied    between   enlarged   spleen,  a  floating   kidney, 


CONCEETIONS  IN   THE   STOMACH  331 

and  malignant  disease  of  the  stomach  or  transverse  colon.  Death 
occurred  from  exhaustion  at  the  end  of  three  years.  At  the  necropsy 
the  tumour  was  found  to  be  within  the  stomach,  and  to  consist  of  a 
kidney-shaped  mass  of  vegetable  matter  weighing  twenty-nine  ounces, 
with  two  other  masses,  each  about  the  size  of  a  hen's  egg. — Kooyker. 

Case  XXXIV.  A  woman,  aged  forty-three  years,  complained  of 
violent  pain  in  the  abdomen  after  meals,  vomiting,  and  constipation. 
Under  the  ensiform  cartilage  a  hard  fixed  and  tender  tumour  could 
be  felt.  After  these  symptoms  had  existed  for  a  considerable  time  an 
exceptionally  violent  fit  of  vomiting  caused  the  expulsion  of  a  large 
sodden  mass  of  vegetable  matter,  after  which  the  patient  made  a  good 
recovery. — Gapelle. 

Case  XXXV.  A  woman,  forty-five  years  of  age,  was  admitted  into 
hospital  for  an  abdominal  tumour  accompanied  by  pain  and  vomiting. 
The  tumour  resembled  a  large  spleen,  but  as  it  was  ascertained  that  the 
patient  had  eaten  a  quantity  of  a  plant  which  superstition  endowed 
with  marvellous  powers  of  healing,  a  diagnosis  of  phytobezoar  was 
made,  and  a  large  mass  of  fibrous  roots  was  successfully  removed 
from  the  stomach  by  operation. — Schreiber  and  Eiselsberg. 

(3)  Gastroliths. — The  subjects  of  this  curious  complaint  are 
usually  men  about  middle  age  who,  in  their  morbid  desire  for 
alcohol,  frequently  have  drunk  varnish,  polish,  or  similar  liquids 
containing  it.  As  a  rule  the  stone  is  too  small  to  be  detected 
during  life,  but  in  the  case  recorded  by  Tidemand  a  large  hard 
tumour  could  be  felt  in  the  epigastrium.  Symptoms  of  gastric 
irritation  with  vomiting  are  almost  always  present,  and  hgemat- 
emesis  is  sometimes  observed.  Death  ensues  from  exhaustion, 
perforation  of  the  stomach,  or  from  intestinal  obstruction 
(Friedlander,  Langenbuch). 

Case  XXXVI.  A  polisher,  forty-four  years  of  age,  was  admitted  into 
hospital  with  the  symptoms  of  chronic  gastritis.  He  was  extremely 
intemperate  in  his  habits,  and  the  gastric  disorder  was  consequently 
attributed  to  chronic  alcoholism.  After  the  lapse  of  some  months  he 
succumbed  to  pulmonary  tuberculosis.  At  the  necropsy  a  chronic 
ulcer  was  found  in  the  stomach  near  the  pylorus,  and  close  to  it  an 
oblong  mass  of  stone  which  measured  ten  centimetres  in  length  and 
five  in  width,  and  weighed  seventy-five  grammes.  Chemical  examina- 
tion showed  the  concretion  to  be  composed  of  shellac,  and  it  was 
afterwards  ascertained  that  the  man  had  been  accustomed  to  drink 
the  polish  he  used  in  his  work,  which  consisted  of  shellac  dissolved  in 
alcohol. — Manasse. 


332  TUMOUES  OP  THE   STOMACH 

Diagnosis. — It  is  probable  that  small  concretions  not 
infrequently  occur  in  young  girls  who  bite  or  suck  their  hair  ; 
but  when  the  habit  is  discontinued,  as  it  usually  is  after  the 
hair  has  been  dressed  in  the  adult  style,  the  material  is  gradually 
evacuated  without  the  production  of  serious  consequences.  In 
one  very  obstinate  case  of  dyspepsia  which  came  under  our 
notice  the  sides  of  the  forehead  had  been  quite  denuded  of  hair 
by  this  pernicious  habit,  and  it  was  only  after  the  dangers 
attending  a  hair-tumour  had  been  explained  to  the  young 
lady,  and  measures  adopted  to  prevent  a  repetition  of  the 
practice,  that  the  gastric  complaint  gradually  disappeared.  It 
is,  therefore,  advisable  that  in  every  case  of  obstinate  dyspepsia 
in  a  girl  careful  inquiries  should  be  instituted  with  regard  to 
her  habits  and  occupations,  and  that,  whenever  an  abdominal 
tumour  is  discovered  in  a  young  adult,  the  possibility  of  a  foreign 
body  in  the  stomach  should  be  borne  in  mind. 

If  pain  and  vomiting  are  prominent  features  of  the  case,  the 
discovery  of  a  tumour  in  the  abdomen  is  usually  suggestive 
of  malignant  disease  of  the  stomach  or  intestine.  In  such 
cases  three  points  deserve  special  attention,  namely,  the  age 
and  sex  of  the  patient,  the  duration  of  the  complaint,  and 
the  character  of  the  tumour.  Cancer  of  the  stomach  is  very 
rare  before  the  age  of  thirty,  and  its  precocious  development  is 
chiefly  met  with  in  men,  while  hair-tumours  commence  at  or 
before  puberty  and  are  practically  confined  to  women.  The 
malignant  disease  is  seldom  preceded  by  symptoms  of  indigestion, 
and  usually  runs  such  a  rapid  course  in  young  persons  that  life  is 
destroyed  within  seven  months  ;  gastric  concretions,  on  the  other 
hand,  are  usually  attended  for  a  long  time  by  pain  and  sickness 
after  meals,  and  seldom  prove  fatal  in  less  than  ten  years.  Lastly, 
a  cancerous  tumour  is  irregular,  nodular,  tender,  more  or 
less  fixed  in  position,  and  of  rapid  growth,  while  in  most 
instances  the  stomach  is  dilated,  marked  cachexia  is  present, 
and  the  gastric  contents  are  devoid  of  free  hydrochloric  acid. 
A  hair-tumour,  on  the  other  hand,  is  globular  or  crescentic 
in  shape,  situated  principally  in  the  left  side  of  the  abdomen,  is 
smooth,  hard,  and  painless  on  palpation,  and  so  freely  movable 
that  it  may  be  pushed  under  the  left  costal  margin.  There  is 
no  ascites  or  jaundice,  the  outlines  of  the  stomach  are  indis- 
tinguishable from  those  of  the  tumour,  and  a  tube  cannot  be 
inserted  more  than  two  inches  into  the  viscus. 


CONCRETIONS   IN   THE   STOMACH  333 

A  painless  tumour  in  the  upper  part  of  the  abdomen,  which  is 
not  attended  by  special  symptoms  and  has  been  discovered  in  an 
accidental  manner,  is  most  likely  to  be  confused  with  an  enlarged 
spleen,  a  floating  kidney,  or  a  faecal  accumulation  in  the  colon. 

If  the  stomach  happens  to  be  dislocated,  as  in  Russell's  case 
(fig.  66),  the  diagnosis  from  an  enlarged  spleen  is  extremely 
difficult.  It  may  usually  be  observed,  however,  that  the 
tumour  is  exceptionally  movable,  and  that  its  length  is  out  of 
proportion  to  its  breadth.  The  inner  margin  is  less  distinct 
than  in  the  case  of  a  spleen,  the  characteristic  notch  is  absent, 
and  the  passage  of  a  soft  tube  or  inflation  of  the  stomach 
will  at  once  show  that  the  tumour  is  gastric  in  origin.  A 
loose  kidney  on  the  left  side  can  usually  be  displaced  down- 
wards as  well  as  upwards,  and  its  point  of  attachment  is  much 
lower  than  that  of  an  enlarged  stomach.  It  also  lies  behind 
the  intestine,  so  that  the  percussion-note  is  resonant  rather 
than  dull,  and  manipulation  is  often  attended  by  pain.  In  case 
of  doubt,  inflation  of  the  stomach  should  be  practised,  when  the 
relation  of  that  organ  to  the  tumour  can  easily  be  ascertained. 

A  f  Eecal  mass  in  the  colon  is  more  irregular  in  shape  and  less 
definite  in  outline  than  a  gastric  concretion.  It  is  less  hard  to  the 
touch,  and  may  even  be  soft  enough  to  indent  with  the  finger, 
while  other  tumours  of  a  similar  character  may  be  found  in  the 
caecum,  sigmoid  flexure,  or  rectum.  The  passage  of  a  tube 
shows  that  the  stomach  is  empty  and  situated  above  the  tumour, 
and  the  administration  of  several  large  enemata  will  either 
diminish  the  size  of  the  mass  or  remove  it  altogether. 

Treatment. — If  the  tumour  is  small  in  size,  it  may  be 
possible  to  secure  its  evacuation  by  an  emetic  ;  but  this  method 
is  always  fraught  with  a  certain  amount  of  danger,  on  account 
of  the  ulceration  of  the  stomach  which  is  often  present.  In 
the  case  of  large  tumours  medicinal  remedies  are  valueless,  and 
recourse  must  be  had  to  an  operation.  In  the  cases  reported  by 
Knowsley  Thornton  and  Schonborn  the  mass  was  successfully 
removed  after  the  nature  of  the  tumour  had  been  determined 
by  an  exploratory  incision,  while  in  that  recorded  by  Schreiber 
a  correct  diagnosis  of  phytobezoar  was  made  by  the  physician 
and  the  concretion  extracted. 


334  TCJMOUKS   OF  THE   STOMACH 


BIBLIOGBAPHY 

Baudamant,  Mem.  de  la  Soc.  Koyale  de  Med.,  1777,  ii.  p.  262. 

Best,  Brit.  Med.  Journ.,  1869,  ii.  p.  630. 

Bollinger,  Munckener  med.  Wochensehr.,  1891,  22,  p.  383. 

Capelle,  Journ.  de  Med.  de  Bruxelles,  Feb.  1861. 

Finder,  Trans.  N.  Y.  Med.  Assoc,  1880. 

Frieclldnder,  C,  Bed.  klin.  Wochensehr.,  1881,  p.  10. 

Gull,  Sir  W.,  Trans.  Clinical  Soc,  iv.  p.  183. 

Inman,  Medical  Times  and  Gazette,  1869,  ii.  p.  6. 

Keiller,  Edin.  Monthly  Journal,  1st  series,  vol.  ix.  p.  933. 

Kooyker,  Zeitschr.  f.  klin.  Med.,  1888,  14,  p.  203. 

Langenbuch,  Verhandl.  der  deut.  Gesellschaft  f.  Chir.,  ix.  Congr.  1881,  p.  54. 

Manasse,  Berl.  klin.  Wochensehr.,  1895,  p.  723. 

May,  Brit.  Med.  Journ.,  1855,  ii.  p.  1147. 

Paton,  Brit.  Med.  Journal,  1902,  i.  p.  147. 

Pollock,  Trans.  Path.  Soc,  iii.  p.  327. 

Prudden,  Proc  N.  Y.  Path.  Soc,  1890,  p.  32. 

Quain,  Trans.  Path.  Soc,  v.  p.  145. 

Ritchie,  Edin.  Monthly  Journ.,  1st  series,  vol.  ix.  p.  931. 

Russell,  Medical  Times  and  Gazette,  1869,  i.  p.  681. 

Sclwnbom,  Berl.  klin.  Wochensehr.,  1883,  17,  p.  260  ;  Archiv  f.  Chirurg.,  188a,  29, 

p.  609. 
Schreiber,  Mittheil.  a.  d.  Grenzgebieten  d.  Medizin  u.  d.  Chirurg.,  1896,  i.  p.  729. 
Schulten,  Mittheil.  aus  d.  Grenzgebieten  d.  Med.  u.  Chir.,  1897,  ii.  p.  289. 
Thornton,  Knoiusley,  Trans.  Path.  Soc,  xxxv.  p.  199. 
Tidemand,  Norsk.  Mag.  f.  Lagevidensk.,  1865,  p.  80. 
Wood,  Medical  Facts  and  Observations,  1800,  viii.  pp.  139-146. 
Yeo,  Dubl.  Journ.  of  Med.  Sci.,  1873,  56,  p.  267. 


335 


CHAPTEE   VI 
CYSTS   OF  THE   STOMACH 

Cheonic  inflammation  of  the  stomach  is  occasionally  accom- 
panied by  the  formation  of  numerous  cysts  about  the  size 
of  henipseeds,  which  project  above  the  surface  of  the  mucous 
membrane  and  are  filled  with  a  clear  fluid.  This  condition 
results  from  obstruction  of  the  mouths  of  the  ducts,  and  the 
consequent  retention  of  the  gastric  secretion  within  the  tubular 
glands.  It  does  not  possess  any  clinical  significance  (Hand- 
field- Jones,  Harris). 

Solitary  cysts  of  the  stomach  are  very  rare,  and  we  have 
been  able  to  find  only  fourteen  cases  recorded  in  the  literature, 
to  which  we  have  added  one  of  our  own.  They  vary  in  size 
from  a  pigeon's  egg  to  a  cocoa-nut,  and  their  contents  usually 
consist  of  altered  blood  or  of  a  pinkish  fluid  containing  crystals 
of  cholesterine.  As  a  rule  they  form  in  the  subserous  tissue  of 
the  posterior  wall  or  upper  margin  of  the  organ,  but  occa- 
sionally they  develop  in  the  submucous  coat.  In  the  former 
case  the  cyst  appears  to  be  external  to  the  stomach,  and  exerts 
deleterious  pressure  upon  the  surrounding  viscera ;  while  in  the 
latter  it  may  partially  occlude  the  lumen  of  the  organ  or,  by 
perforating  the  muscular  tunic,  project  externally  as  well  as 
beneath  the  mucous  membrane.  The  cases  at  our  disposal 
afford  examples  of  seven  varieties  of  cystic  disease. 

(1)  Dermoid  Cyst.— The  sole  example  of  this  rare  affection 
was  recorded  by  Kuysch  in  the  year  1732.  It  consisted  of  a 
small  tumour  of  the  gastric  wall  which  contained  hair. 

(2)  Serous  Cysts. — These  usually  develop  between  the 
muscular  and  serous  coats  of  the  stomach  on  the  anterior 
surface  or  near  the  upper  margin.  In  the  case  described  by 
Albers  the  tumour  occupied  the  lesser  curvature,  and  measured 
two  and  a  quarter  inches  in  length.  Occasionally  they  become 
pedunculated,  and  sometimes  muscular  tissue  is  found  in  their 
walls. 


336  TUMOURS  OF  THE   STOMACH 

Case  XXXVII.  A  man,  aged  twenty-one,  succumbed  to  concussion 
of  the  brain.  Attached  to  the  cardiac  end  of  the  stomach,  just  below 
the  diaphragm,  there  was  a  cyst  the  size  of  a  pigeon's  egg.  Micro- 
scopical examination  showed  the  wall  of  the  cyst  to  be  composed  of 
unstriped  muscular  tissue,  which  was  arranged  in  two  longitudinal 
layers  with  a  transverse  one  interposed  between  them.  The  wall  was 
well  supplied  with  blood-vessels,  and  much  blood  was  effused  between 
the  muscle-bundles.  The  cyst  was  lined  by  a  single  layer  of  stumpy 
epithelioid  cells,  some  of  which  were  cuboidal. — Hebb. 

Case  XXXVIII.  A  woman  died  at  the  age  of  thirty  years  from 
cancer  of  the  pylorus  with  secondary  deposits  in  the  liver.  During  life 
a  smooth  and  very  movable  tumour  was  detected  in  the  epigastrium. 
After  death,  in  addition  to  the  cancerous  disease,  there  was  found  a 
cyst  about  the  size  of  the  foetal  head  at  term,  which  was  attached  by 
a  short  pedicle  to  the  pyloric  end  of  the  stomach,  and  was  filled  with 
a  reddish  fluid.— Finnel. 

(3)  Hydatid  Cysts. — These  are  represented  by  two  examples. 
In  the  one  described  by  Bochlendorff  the  tumour  originated  in 
the  vicinity  of  the  stomach,  and  involved  the  viscus  during 
the  course  of  its  development,  while  in  that  recorded  by 
Castellvi  y  Panares  the  gastric  wall  seems  to  have  been  primarily 
affected. 

(4)  Blood  Cysts. — Our  series  contains  four  instances  of  this 
variety.  In  three  cases  the  tumour  was  of  large  size,  and  its 
contents  consisted  of  coffee-  or  chocolate-coloured  fluid  contain- 
ing a  large  quantity  of  mucus,  blood-corpuscles,  and  pus  cells  ; 
while  in  the  fourth  the  nature  of  the  cyst  was  less  definite, 
but  the  pinkish  colour  of  its  contents  and  the  presence  of 
cholesterine  crystals  seemed  to  indicate  a  hsernorrhagic  origin. 

Case  XXXIX.  A  man,  aged  thirty-eight  years,  had  suffered  for  five 
years  with  pain  and  sickness  after  food.  At  first  these  symptoms 
had  been  intermittent,  but  for  six  months  the  pain  had  been  more  or 
less  constant,  and  vomiting  had  occurred  regularly  from  half  an  hour 
to  an  hour  and  a  half  after  meals.  When  admitted  into  hospital  he 
was  very  emaciated  and  vomited  three  times  a  day.  There  was  no 
cachexia  and  the  appetite  continued  good.  The  stomach  was  dilated 
and  its  lower  border  extended  below  the  level  of  the  navel.  Four 
litres  of  fluid  were  removed  by  means  of  a  soft  tube,  and  the  regular 
employment  of  lavage  greatly  relieved  the  symptoms.  A  sense  of 
resistance  could  be  detected  on.  palpation  of  the  epigastrium,  which 
was  thought  to  be  the  left  lobe  of  the  liver.  Three  months  later  an 
ill-defined  rounded  tumour  could  be  felt  in  the  epigastrium  and  right 


CYSTS   OF  THE   STOMACH  337 

hypochondrium.  As  fluctuation  was  present  it  was  regarded  as  a 
hydatid  cyst  of  the  liver,  and  aspirated,  with  the  result  that  950 
grammes  of  a  mucoid  bilious  fluid  were  withdrawn.  A  month  after- 
wards the  cyst  had  regained  its  former  size,  and  when  punctured 
once  more  700  grammes  of  brownish  fluid  were  evacuated.  The 
relief  afforded  by  the  operation  was  only  temporary,  since  the 
abdominal  pain  and  sickness  soon  returned  and  about  the  tenth  day 
jaundice  set  in.  At  the  end  of  three  weeks  the  tumour  was  again 
prominent,  and  a  trocar  was  inserted  for  the  third  time,  with  relief  to 
the  jaundice.  After  an  interval  of  another  three  weeks,  during  which 
the  icterus  returned,  a  fourth  aspiration  withdrew  900  c.c.  of  a  chocolate- 
coloured  fluid  containing  pus.  Although  the  jaundice  disappeared 
and  the  patient  felt  much  relieved,  it  was  felt  necessary  to  drain  the 
cyst  in  a  more  efficient  manner.  Unfortunately  general  peritonitis 
was  set  up  by  the  escape  of  some  of  the  contents  of  the  tumour 
charing  the  operation,  and  the  patient  died. 

Necropsy. — The  stomach  was  much  dilated,  and  the  pylorus  was 
compressed  by  a  large  cyst  connected  with  the  lesser  curvature  and 
extending  into  the  lesser  cavity  of  the  peritoneum.  The  cyst  did  not 
communicate  with  the  stomach,  but  opened  into  a  small  cavity 
situated  in  the  muscular  coat  of  the  viscus  at  the  pylorus.  The 
contents  consisted  of  altered  blood,  mucus,  and  a  little  pus,  and  the 
icterus  was  found  to  have  arisen  from  the  pressure  of  the  sac  upon  the 
gall-bladder  and  bile-duct  at  the  hilus  of  the  liver.  The  lining 
membrane  of  the  cyst  was  extremely  vascular. — Rendu. 

Case  XL.  A  female,  twenty-two  years  of  age,  was  suddenly 
seized  with  severe  pain  in  the  left  side  of  the  abdomen,  which  was  in- 
creased by  inspiration.  The  bowels  were  obstinately  confined.  After 
a  week  in  bed  the  pain  was  relieved  but  never  quite  disappeared,  and 
vomiting  occurred  occasionally.  Soon  afterwards  the  patient  noticed  a 
small  tumour  in  the  left  hypochondrium,  which  gradually  increased 
in  size  and  gave  rise  to  excruciating  pain.  As  the  tumour  appeared 
to  be  cystic,  it  was  punctured,  and  a  quantity  of  clear  albuminous  fluid 
was  withdrawn,  after  which  the  pain  disappeared  and  the  tumour 
could  hardly  be  detected.  About  a  fortnight  later,  however,  the  pain 
returned,  and  the  tumour  was  found  to  have  regained  its  former 
dimensions.  A  second  puncture  resulted  in  the  evacuation  of  a 
similar  quantity  of  fluid,  but  the  cyst  filled  up  again  in  a  couple  of 
weeks.  At  this  period  it  was  noted  that  the  abdomen  was  enlarged 
and  the  tumour  occupied  the  left  hypochondriac,  umbilical,  and  left 
lumbar  regions,  extending  from  the  margin  of  the  ribs  to  the  level  of 
the  iliac  crest  and  to  the  right  of  the  median  line  of  the  belly.  The 
surface  was  smooth,  the  percussion-note  was  dull,  and  stomach 
resonance  could  be  detected  between  the  tumour  and  the  diaphragm. 
Distinct  fluctuation  was  perceptible.     Two  months  later  the  patient 

Z 


338  TUMOUKS  OF  THE   STOMACH 

was  readmitted  into  hospital  with  the  symptoms  and  signs  of  acute 
phthisis,  but  she  still  complained  of  pain  in  the  tumour,  which, 
however,  did  not  appear  to  have  increased  in  size.  Death  occurred 
from  acute  peritonitis  about  fourteen  months  after  the  first  symptoms 
of  the  abdominal  complaint  had  appeared.  At  the  necropsy  a  cyst 
the  size  of  the  foetal  head  at  term  was  found  connected  with  the 
posterior  wall  of  the  stomach.  Eupture  of  its  wall  had  set  up  fatal 
peritonitis.- — Gallois,  Honlang,  and  Leflaive. 

Case  XLI.  A  middle-aged  woman  had  suffered  for  a  few  months 
from  vomiting,  pain  in  the  abdomen,  and  loss  of  flesh.  Examination 
showed  a  large  tumour  in  tbe  umbilical  region  and  left  hypochondrium, 
which  was  somewhat  movable,  smooth,  non-tender,  dull  on  percus- 
sion, and  cystic  in  character.  When  the  abdomen  was  opened  the 
cyst  was  found  to  be  connected  with  the  anterior  wall  of  the  stomach, 
and  to  contain  a  reddish-brown  fluid  with  crystals  of  cholesterine. 
After  death  another  large  cyst  was  discovered  between  the  serous 
and  muscular  coats  of  the  organ,  on  the  posterior  surface,  and  two 
others  existed  in  the  wall  of  the  jejunum. — Anderson. 

Case  XLII.  A  man  aged  thirty-three  died  of  enteric  fever.  In 
the  wall  of  the  stomach,  close  to  the  pyloric  orifice,  there  was  a  cystic 
tumour  the  size  and  shape  of  a  walnut.  The  tumour  projected 
both  externally  beneath  the  peritoneum  and  internally  beneath  the 
mucous  membrane,  having  perforated  the  muscular  coat  of  the  organ. 
It  thus  possessed  the  shape  of  an  hour-glass.  Internally  its  size  was 
sufficient  to  completely  occlude,  as  a  valve,  the  pyloric  orifice ;  but 
by  pressure  the  fluid  might  be  emptied  into  the  subperitoneal  half  of 
the  cyst,  when  the  mucous  membrane  would  hang  loose.  With  the 
finger  the  constricted  orifice  of  communication  between  the  two  halves 
of  the  cyst  might  easily  be  felt.  There  were  no  signs  of  inflammation 
about  the  cyst,  nor  were  its  mucous  or  serous  investments  at  all 
thickened.  When  opened  the  cyst  was  found  to  contain  about  half 
an  ounce  of  an  opaque  pinkish  fluid,  glittering  with  plates  of 
cholesterine.  No  signs  of  hydatid  could  be  detected. — Shane, 
reported  by  Hutchinson. 

In  the  following  case  a  blow  on  the  abdomen  appears  to 
have  been  the  cause  of  the  disease  : 

Case  XLIII.  A  man,  aged  twenty-three,  received  a  severe  crush 
in  the  upper  part  of  the  abdomen,  which  rendered  him  unconscious. 
When  he  revived  he  complained  of  great  pain  in  the  left  side  of  the 
chest  and  abdomen  and  expectorated  a  little  blood.  The  abdomen 
was  found  to  be  distended  and  very  tender  upon  pressure,  but  no 
tumour  could  be  detected.  The  urine  was  blood-stained,  and  subse- 
quently the  stools  contained  altered  blood.     There  was  slight  pyrexia 


CYSTS   OF  THE   STOMACH  339 

for  three  days.  On  the  sixth  day  after  the  accident  these  various 
symptoms  had  subsided  and  the  patient  appeared  to  be  quite  well. 
During  the  third  week,  however,  considerable  pain.was  experienced 
in  the  left  side  of  the  abdomen,  and  a  tumour  about  the  size  of  an 
apple,  elastic  and  slightly  pulsatile,  was  felt  in  the  affected  region. 
Vomiting  now  took  place  each  night,  the  pain  increased,  and  the 
tumour  rapidly  enlarged  and  extended  to  the  right  of  the  median  line. 
Finally  symptoms  of  intestinal  obstruction  appeared,  vomiting  was 
urgent,  and  the  abdomen  became  distended.  On  puncturing  the 
tumour  three  quarters  of  a  litre  of  a  gummy  fluid  containing  altered 
blood  was  withdrawn,  after  which  the  mass  disappeared  and  the 
abdominal  symptoms  subsided.  After  a  short  interval  the  tumour 
reappeared  and  the  pain  and  vomiting  returned.  The  appetite, 
however,  remained  good  and  there  was  no  pyrexia.  In  the  left 
hypochondrium,  between  the  navel  and  the  ribs,  a  large  elastic  swelling 
could  be  felt,  the  outline  of  which  was  fairly  defined  below  and  to 
the  right  but  indistinct  above.  The  tumour  was  dull  on  percussion, 
fixed,  and  apparently  lay  above  the  transverse  colon.  An  exploratory 
operation  was  determined  upon,  and  when  the  belly  was  opened 
the  tumour  was  found  to  be  a  large  cyst  situated  in  the  anterior 
wall  of  the  stomach  and  beneath  its  serous  coat.  There  were  no 
adhesions.  The  wall  of  the  cyst  was  two  or  three  centimetres  in 
thickness,  and  it  contained  three  litres  of  black  blood.  Drainage, was 
effected  and  complete  recovery  ensued. — Ziegler. 

(5)  Lymphangioma,  or  Chylous  Cyst,  has  been  described  by 
Engel-Eeimers.  The  patient  was  a  man  about  fifty  years  of 
age,  who  succumbed  to  hsematemesis.  After  death  an  ulcer  was 
found  upon  the  posterior  surface  of  the  stomach,  which  was 
adherent  to  the  pancreas.  The  lesser  curvature  was  greatly 
contracted,  and  upon  the  outer  surface  there  was  a  soft  hemi- 
spherical swelling,  covered  by  peritoneum,  which  contained  a 
milky  fluid.  The  contraction  of  the  upper  border  of  the 
stomach  had  probably  obstructed  some  of  the  lymphatic  trunks 
which  traverse  the  subperitoneal  tissue  in  that  region  of  the 
organ. 

(6)  Cysts  from  New  Growths. — These  are  usually  too  small 
to  be  recognised  during  life.  Billroth,  however,  has  recorded 
an  instance  in  which  an  enormous  cyst  of  the  stomach  ensued 
from  the  degeneration  of  a  sarcoma,  while  in  the  following  case 
the  primary  disease  appears  to  have  been  a  submucous  lipoma  : 

Case  XLIV.  A  man,  aged  sixty -two,  when  apparently  in  good 
health,  was  seized  with  violent  pain  in  the  right  side  of  the  belly  and 

z  2 


340  TUMOUES  OF  THE   STOMACH 

vomiting.  These  symptoms  continued  and  slight  jaundice  developed. 
Three  days  later  the  vomit  resembled  coffee-grounds  and  the  tempera- 
ture rose  to  101°.  At  the  end  of  the  week  the  pyrexia  disappeared 
and  the  patient  seemed  much  better.  Three  weeks  after  the  com- 
mencement of  the  illness,  however,  he  again  vomited  altered  blood, 
and  complained  of  pain  and  tenderness  at  the  epigastrium.  He  died 
of  exhaustion  a  fortnight  later. 

Necropsy.  '  The  stomach  appeared  to  be  enormously  dilated,  and 
in  endeavouring  to  remove  it  it  was  ruptured  in  two  or  three  places, 
and  fully  a  quart  of  grey  grumous  fluid  escaped.  After  tying  the 
duodenum  and  oesophagus  and  removing  the  entire  mass,  it  was 
found  that  we  had  really  ruptured  a  cyst  which  completely  enveloped 
the  stomach,  extending  from  the  liver  on  the  right  to  the  spleen  on 
the  left,  and  closely  adherent  to  both.  It  surrounded  the  common 
bile-duct,  which  was  dilated  to  the  size  of  the  little  finger,  descended 
to  the  lower  end  of  the  vertical  portion  of  the  duodenum,  and  enfolded 
the  whole  of  the  great'  curvature  of  the  stomach,  forming  adhesions 
with  everything  with  which  it  came  in  contact.  Besides  the  escaped 
fluid  it  contained  numerous  lumps  of  a  fatty  substance  of  the  size  of 
cardamom  seeds,  and  loosely  attached  to  its  walls  were  masses  of 
these  fatty  lumps,  aggregated  together,  with  black  streaks  intermingled. 
These  latter  were  the  remains  of  extravasated  blood.  The  stomach 
showed  a  punched-out  ulcer  the  size  of  a  thumb-nail,  with  the  open 
mouth  of  a  small  blood-vessel  in  its  edge.  Around  it  for  some 
distance  the  mucous  membrane  was  congested  and  covered  with 
bleeding  points.  Only  a  thin  layer  of  connective  tissue  intervened 
between  the  bottom  of  the  ulcer  and  the  cyst.' — H.  H.  Bead. 

In  the  next  case  the  nature  of  the  cyst  was  indefinite,  but 
from  the  statements  regarding  a  '  fibrous  reticulum  '  and '  lyniph- 
angiomatous  structure '  it  was  possibly  due  to  the  degeneration 
of  a  growth : 

Case  XLV.  A  woman,  aged  twenty-two,  was  admitted  into  the 
London  Hospital  for  pain  and  swelling  of  the  abdomen.  The 
umbilical  and  hypogastric  regions  were  occupied  by  a  large  tumour, 
which  could  be  moved  slightly  in  a  lateral  direction  and  also 
descended  on  inspiration.  It  was  painless,  dull  on  percussion,  and 
felt  like  a  tense  cyst.  The  opinion  being  that  the  tumour  was  a  cyst 
of  the  ovary,  an  operation  was  undertaken  for  its  removal ;  but  when 
the  belly  was  opened  the  cyst  wTas  found  to  be  attached  to  the  lower 
border  of  the  stomach.  A  portion  of  it  was  removed,  but  the  patient 
died  of  peritonitis. 

Necropsy.  '  On  the  peritoneal  surface  of  the  posterior  wall  of  the 
stomach,  about  two  inches  from  the  pylorus,  are  the  remains  of  a  large 


CYSTS   OF  THE   STOMACH 


341 


cyst,  the  greater  part  of  which  was  removed  during  life.  This  cyst, 
which  has  a  smooth  lining  membrane,  is  separated  from  the  gastric 
wall  by  a  smaller  cyst,  of  the  size  of  a  turkey's  egg,  which  forms  a 
peduncle  to  it.  The  cavity  of  the  smaller  cyst,  which  communicates 
by  a  wide  aperture  with  the  larger  one,  is  partly  occupied  by  a 
fibrous  trabecular  structure.  Close  to  the  pylorus,  and  in  the  lesser 
curvature,  are  two  cysts  similar  to  the  last,  connected  with  the  serous 
surface  ;  one  is  about  the  size  of  a  pigeon's  egg,  and  the  other  twice 
as  big.     They  contained  serous  fluid  with  some  dark  material.     At 


*\;.' 


Fig.  67. — Portion  of  a  stomach  showing  an  enormous  dependent  cyst  growing 
from  the  posterior  wall.     (London  Hospital  Museum.) 


this  part  also  there  are  some  irregularly  lobulated  prominences  of  the 
mucous  surface,  one  as  large  as  half  an  orange  ;  and  somewhat 
'further  from  the  pylorus,  on  the  posterior  wall,  is  a  second  projection 
of  the  mucous  surface,  similar  to  the  first,  but  smaller,  the  two  being 
separated  by  a  level  piece  where  the  large  cyst  is  connected  with  the 
gastric  wall.  In  the  smaller  elevation  there  is  an  opening  at  one 
point,  where  the  wall  of  a  cavity  has  been  opened  by  ulceration, 
through  which  a  delicate  and  open-meshed  fibrous  reticulum  of 
degenerated  growth  projects.     Arising  from  the  peritoneal  surface  at 


342  TUMOUES   OF  THE   STOMACH 

this  part  is  what  looks  like  a  mass  of  adipose  tissue  the  size  of  an 
egg.  Sections  from  it  show  spaces  of  varying  size  in  a  fibrous 
reticulum  resembling  a  lymphangioma,  and  some  larger  cysts.  The 
black  pulpy  substance  in  the  cyst  contained  variously  shaped  cells, 
some  granular  matter  and  fat.' 

Symptoms  and  Physical  Signs. — The  clinical  aspect  of  the 
disease  varies  according  to  the  size  and  position  of  the  cyst. 
When  it  is  small  or  attached  to  the  cardiac  end  of  the  stomach 
it  usually  escapes  detection,  and  is  only  discovered  after  death 
(Ikiysch,  Engel-Reimers,  Hebb) ;  and  even  in  Sloane's  case, 
where  it  was  proved  to  be  capable  of  obstructing  the  pylorus, 
no  indication  of  its  presence  had  been  forthcoming  during  life. 
The  larger  varieties,  on  the  other  hand,  are  always  attended 
by  urgent  gastric  symptoms,  and  not  infrequently  by  others 
which  arise  from  pressure  upon  neighbouring  viscera. 

When  the  disease  is  due  to  injury  or  to  extravasation  of 
blood  into  the  substance  of  a  benign  tumour  (Ziegler,  Read), 
the  complaint  may  commence  abruptly  with  violent  pain, 
vomiting,  and  collapse ;  but  as  a  rule  discomfort  in  the 
abdomen,  occasional  sickness  and  constipation  are  the  first- 
symptoms  to  attract  attention  (Eendu,  Gallois).  Gradually 
the  pain  increases  in  severity,  and  becomes  localised  to  the 
epigastrium  or  to  one  hypochondrium,  vomiting  occurs  after 
meals,  and  the  patient  loses  flesh  and  strength.  Sometimes 
the  pain  is  paroxysmal  in  character  and  appears  to  radiate  from 
the  tumour,  which  becomes  exquisitely  tender ;  or  it  may  be 
only  when  the  patient  wTalks  about  or  stoops  that  he  experiences 
any  discomfort.  The  tongue  is  often  furred  and  the  bowels 
confined,  but  it  is  noticeable  that  the  appetite  usually  continues 
good  and  there  is  neither  elevation  of  temperature  nor  cachexia. 
In  the  early  stages  of  the  complaint  examination  of  the  abdo- 
men may  reveal  only  a  little  fulness  or  slight  resistance  in  the 
epigastrium,  but  as  the  cyst  increases  in  size  it  gives  rise  to  an 
ill-defined  smooth  tumour,  which  encroaches  upon  one  or  other 
hypochondrium.  There  may  be  some  mobility  with  respira- 
tion, but  unless  the  cyst  is  pedunculated,  as  in  Finnel's  case,  it 
usually  appears  to  be  attached  to  one  of  the  solid  organs  in  its 
vicinity.  At  this  stage  it  is  almost  always  possible  to  detect 
fluctuation  in  the  tumour,  or  else  the  elastic  sensation  it  com- 
municates to  the  fingers  clearly  indicates  that  it  contains  fluid. 
Exploration  with  a  hollow  needle  or  trocar  was  performed  in 


CYSTS   OF  THE   STOMACH  343 

three  cases,  with  the  result  that  from  half  a  pint  to  two  pints 
of  thick  grumous  fluid  were  withdrawn.  The  operation  was 
followed  by  a  disappearance  of  the  tumour,  with  relief  of  the 
symptoms  for  about  ten  days,  after  which  time  the  cyst  again 
filled  up  and  the  pain  and  vomiting  returned.  The  principal 
complications  of  the  disease  are  due  to  the  pressure  it  exerts 
upon  the  surrounding  structures.  When  the  cyst  extends  to 
the  right  of  the  median  line  of  the  abdomen,  it  may  compress 
the  pylorus  or  the  duodenum  and  give  rise  to  dilatation  of  the 
stomach  (Eendu),  or  it  may  occlude  the  bile-duct  or  the  portal 
vein  and  lead  to  jaundice  or  ascites.  Unless  subjected  to  surgical 
treatment,  large  cysts  of  the  stomach  usually  end  fatally,  either 
from  general  exhaustion,  spontaneous  rupture,  and  peritonitis,  or 
from  the  effects  of  pressure  upon  the  bile-duct  or  portal  vein. 

Diagnosis. — Small  tense  cysts  attached  to  the  outer  wall 
of  the  stomach  are  difficult  to  distinguish  from  solid  tumours. 
In  the  case  of  large  cysts,  the  presence  of  fluctuation  indi- 
cates at  once  that  the  tumour  contains  fluid,  and  the  chief 
difficulty  is  to  determine  the  organ  that  is  involved.  The 
extreme  rarity  of  a  cyst  of  the  gastric  wall  naturally  predis- 
poses to  the  view  that  some  other  viscus  is  affected,  and  accord- 
ingly we  find  that  in  the  recorded  cases  the  diagnosis  varied 
between  a  cyst  or  abscess  of  the  liver,  spleen,  kidney,  pancreas, 
or  mesentery,  while  in  one  instance  cancer  of  the  stomach  was 
suspected. 

A  cyst  of  the  liver  is  almost  always  a  hydatid,  and  is 
seldom  attended  by  any  particular  symptoms  until  it  has 
reached  a  considerable  size  or  has  exerted  pressure  upon  some 
external  structure.  It  usually  forms  a  rounded,  elastic,  non- 
tender  tumour,  which  moves  with  respiration  and  cannot  be  dis- 
tinguished from  the  liver  by  palpation  or  percussion.  A  gastric 
cyst,  on  the  other  hand,  is  accompanied  by  severe  pain  and 
vomiting,  is  less  indistinct  in  outline,  and  is  often  separated 
from  the  lower  border  of  the  liver  by  an  area  of  resonance. 

The  absence  of  fever  and  the  very  slow  growth  serve  to 
distinguish  a  cyst  from  an  abscess.  A  cyst  of  the  spleen 
appears  to  spring  from  the  left  hypochondrium.  It  is  painless, 
clearly  defined,  dull  on  percussion,  and  moves  readily  with  respi- 
ration. As  a  rule  the  edge  of  the  spleen  can  be  felt  either 
above  or  below  the  margin  of  the  tumour.  A  cyst  of  the 
kidney  or  a  hydronephrosis  is  situated  in  the  loin  rather  than 


344  TUMOURS   OF  THE    STOMACH 

in  the  epigastrium  or  hypochondriurn,  and  forms  a  well-defined 
tumour,  which  can  be  grasped  between  the  hands.  It  is 
resonant  on  light  percussion,  immovable  on  respiration,  and 
there  is  usually  a  history  of  renal  colic  or  hematuria,  with  a 
diminished  secretion  of  urine.  A  cyst  of  the  pancreas  is  situated 
in  the  median  line,  and  may  be  attended  by  severe  pain  in  the 
back  and  vomiting.  At  first  it  is  covered  by  the  stomach  and 
colon,  but  as  it  comes  forward  it  may  stretch  the  gastro- 
colic omentum  and  present  a  dull  note  on  percussion.  It  is 
fixed,  non-tender,  and  may  usually  be  distinguished  from  the 
stomach  by  inflating  the  latter  organ  with  air  or  gas.  A  cyst 
of  the  mesentery,  such  as  has  been  described  by  Hahn,  is  more- 
movable  than  the  gastric  affection,  more  distinct  in  outline, 
and  an  area  of  resonance  often  intervenes  between  the  tumour 
and  the  stomach. 

Encysted  collections  of  fluid  situated  between  the  layers  of 
the  great  omentum  or  in  the  lesser  cavity  of  the  peritoneum 
occasionally  give  rise  to  tumours  which  in  their  symptoms  and 
physical  signs  closely  resemble  cysts  of  the  gastric  wall.  Two 
cases  of  this  description  have  come  under  our  notice,  the  first 
of  which  consisted  of  a  hydatid  attached  to  the  posterior 
aspect  of  the  stomach,  and  the  second  of  a  cyst  of  hemorrhagic 
origin. 

Case  XLVI.  A  middle-aged  woman  was  sent  to  us  by  Dr.  Latham, 
of  Barnsbury,  suffering  from  tumour  in  the  abdomen.  It  appeared 
from  her  history  that  she  had  been  in  good  health  until  about  four 
months  previously,  when  she  began  to  experience  severe  attacks  of 
pain  in  the  abdomen,  followed  by  vomiting.  The  appetite  remained 
good,  and  there  was  no  bleeding  from  the  stomach,  but  she  lost 
much  flesh  and  grew  very  weak.  About  a  month  before  we  saw  her 
she  noticed  that  her  abdomen  was  swelling.  There  was  no  family 
history  of  importance,  nor  had  the  patient  suffered  from  an  injury. 
On  examination  she  was  found  to  be  very  thin,  but  not  anaemic.  The 
upper  half  of  the  abdomen  was  distended,  and  on  palpation  a  rounded 
tumour  of  somewhat  indefinite  outline  could  be  detected  in  the 
epigastric,  umbilical,  and  right  hypochondriac  regions.  The  swelling 
was  smooth,  painless,  elastic,  freely  movable  with  respiration,  and  could 
be  appreciably  displaced  in  all  directions  by  pressure  with  the  hands. 
The  percussion-note  was  dull  over  the  centre  of  the  tumour,  but 
sub-tympanitic  over  its  upper  third.  There  was  no  ascites  or  enlarged 
veins. 

Inflation  of  the  stomach  showed  that  the  viscus  was  considerably 


CYSTS  OF  THE   STOMACH  345 

dilated  and  lay  in  front  of  the  upper  and  left  segment  of  the  tumour, 
and  the  introduction  of  air  into  the  colon  indicated  that  the  bowel 
was  attached  to  its  right  side  and  lower  margin.  After  a  test  meal 
the  gastric  contents  gave  a  positive  reaction  for  free  hydrochloric  acid 
and  were  devoid  of  lactic  acid.  The  other  organs  of  the  body  were 
apparently  healthy.  The  pain  and  vomiting  of  which  the  patient 
complained,  coupled  with  the  fact  that  the  stomach  lay  across  the 
upper  part  of  the  tumour,  seemed  to  indicate  that  the  symptoms  were 
produced  by  stretching  of  the  pyloric  end  of  the  organ  or  the 
duodenum;  while  the  physical  characters  of  the  swelling  indicated 
that  it  was  probably  a  cyst.  The  patient  was  accordingly  admitted 
into  the  London  Temperance  Hospital  for  surgical  treatment  under 
the  care  of  Mr.  Paterson.  When  the  abdomen  was  opened  a  large 
cyst  presented  itself,  over  the  upper  part  of  which  the  pyloric  end 
of  the  stomach  and  the  duodenum  were  tightly  stretched  and  firmly 
adherent.  The  fundus  of  the  stomach  was  dilated  and  situated  in  the 
left  hypochondrium,  and  the  transverse  colon  extended  over  the  right 
margin  of  the  tumour.  An  incision  evacuated  forty-six  ounces  of  a 
brownish-coloured  fluid,  which  contained  numerous  fragments  of  fibrin 
of  the  shape  of  melon-seeds  and  two  small  flakes  of  black  pigment, 
but  no  hooklets.  The  cyst  appeared  to  be  situated  in  the  lesser 
cavity  of  the  peritoneum,  and  was  so  firmly  adherent  to  the  transverse 
mesocolon,  the  stomach,  and  intestine,  that  it  was  impossible  to 
remove  it.  A  drainage-tube  was  consequently  inserted,  and  after 
about  two  months  the  cavity  was  almost  closed.  The  vomiting 
ceased  immediately  after  the  operation,  and  the  patient  was  dis- 
charged from,  the  hospital  in  good  health. 

Treatment. — In  the  initial  stages  of  the  complaint  the  pain 
and  vomiting  may  require  to  be  controlled  by  sedative  drugs, 
and  if  the  stomach  is  dilated  lavage  may  be  employed  with 
advantage.  As  soon,  however,  as  a  cystic  tumour  can  be 
detected,  an  operation  should  be  undertaken,  with  a  view  to 
drainage.  An  exploratory  puncture  is  more  dangerous  than 
a  carefully  performed  laparotomy,  and  any  attempt  to  aspirate 
the  cyst  is  a  dangerous  procedure,  as  in  one  of  the  recorded 
cases  it  was  followed  by  fatal  peritonitis. 


346  TUMOUES   OF  THE   STOMACH 


BIBLIOGBAPHY 

Albers,  Erlauterungeu,  iv.  p.  151. 

Anderson,  Brit.  Med.  Journal,  1898,  i.  p.  426. 

Bochlendorff,  Beitrag  zu  Heilk.  Biga  1853,  ii.  445. 

Castellvi  y  Pallaris,  Abeja  Med.,  Barcel.  1847,  i.  353. 

Engel-Beimers,  Deut.  Arch.  i.  klin.  Med.,  1879,  23,  p.  632. 

Finnel,  N.  Y.  Med.  Journ.,  1874,  20,  p.  640. 

Gallois,  Honlang,  &  Leflaive,  Bullet.  Soc.  Anatom.,  1884,  p.  556. 

Hebb,  Path.  Soc.  Trans.,  xlix.  p.  94. 

London  Hospital  Museum  Catalogue,  No.  1139. 

Bead,  New  York  Med.  Becord,  1882,  p.  628. 

Bendu,  Bullet.  Soc.  Anat.,  1880,  p.  120. 

Ruyscli,  Adversaria  Ana,  1732,  torn.  iii.  p.  1. 

Shane,  Path.  Soc.  Trans.,  viii.  p.  218. 

Ziegler,  Munch,  med.  Wochenschr.,  1894,  p.  103. 


347 


CHAPTEE   VII 

BENIGN  TV  MOVES 

The  benign  tumours  of  the  stomach  and  duodenum  which 
have  not  been  described  in  the  previous  chapters  are  myomata, 
fibromata,  lipomata,  lymphadenomata,  myxomata,  osteomata, 
and  aneurysms.  They  are  all  very  rare,  and,  with  perhaps 
the  exception  of  the  first,  are  practically  devoid  of  clinical 
interest. 

(1)  Myoma. — This  was  first  described  in  1762  by  Morgagni, 
since  which  time  more  than  forty  other  cases  have  been 
recorded.  As  a  rule  it  takes  the  form  of  an  oval  or  round, 
firm,  solitary  tumour  situated  near  the  cardiac  orifice  or  at 
the  greater  curvature,  but  it  is  sometimes  encountered  in  the 
pyloric  end  of  the  stomach  or  in  the  duodenum  (Wesener).  In 
most  cases  it  does  not  exceed  the  size  of  a  pea  or  a  cherry,  and 
occupies  the  substance  of  the  gastric  wall ;  but  occasionally  it 
forms  an  enormous  lobulated  or  knotty  tumour,  which  projects 
into  the  abdominal  cavity  beneath  the  peritoneum.  On 
section  the  growth  is  found  to  have  originated  in  the  mus- 
cular coat,  and  presents  a  brown  or  milk-white  colour,  and 
on  microscopical  examination  it  is  seen  to  consist  of  inter- 
lacing bundles  of  unstriped  muscle,  mixed  with  strands  of 
fibrous  tissue  and  arranged  in  concentric  layers.  The  tumour 
is  of  slow  growth  and  is  usually  met  with  in  men  of  middle 
age.  The  submucous  variety  is  prone  to  undergo  cystic 
degeneration  and  to  become  pedunculated,  while  the  subserous 
form  occasionally  assumes  a  sarcomatous  character  (Bro- 
dowski) .  Kidd  reported  a  submucous  fibro-myoma,  two  inches  in 
length  and  three-quarters  of  an  inch  in  width,  which  involved 
the  cardiac  orifice,  and  Vogel  one  about  the  size  of  an  almond 
which  was  situated  near  the  lower  end  of  the  oesophagus. 
V.  Erlach  is  said  to  have  removed  a  myoma  from  the   stomach 


348  TUMOUES  OF  THE   STOMACH 

which  weighed  5,400  grammes,  v.  Eiselsberg  one  about  the  size  of 
a  man's  head,  and  Kunze  a  lipomyoma  251  grammes  in  weight. 
Symptoms. — Small  myomata  are  not  accompanied  by  any 
special  symptoms  unless  the  mucous  membrane  which  covers 
them  has  undergone  ulceration  or  they  happen  to  obstruct  one 
of  the  orifices  of  the  stomach.  In  the  former  case  the  patient 
may  suffer  from  pain  after  food  and  repeated  attacks  of 
ha3matemesis,  while  in  the  latter  there  is  dysphagia  or  periodic 
vomiting.  Herhold  has  recorded  an  example  of  myoma  in  a 
woman  thirty-seven  years  of  age  who  for  three  years  had 
suffered  from  severe  vomiting  after  meals.  The  stomach  was 
dilated  and  the  vomit  contained  free  hydrochloric  acid.     An 


Fig.  68. — Papilloma  of  the  pylorus.     (Museum  of  the  Eoyal  College  of 
Surgeons.) 

exploratory  operation  showed  the  existence  of  a  myoma  about 
the  size  of  a  hazel-nut,  which  had  produced  obstruction  of 
the  pylorus.  The  duodenal  myoma  described  by  Wesener  was 
accompanied  by  vomiting  and  emaciation,  and  the  signs  of 
dilatation  of  the  stomach,  which  caused  it  to  be  mistaken  for 
cancer  of  the  pylorus. 

The  subject  of  Kunze's  case  was  a  man  aged  fifty-two,  who 
had  suffered  from  abdominal  pain  for  fourteen  years.  There 
was  no  vomiting  or  cachexia,  but  he  was  extremely  emaciated. 
On  examination  a  tumour  about  the  size  of  a  man's  fist  could 
be  felt  close  to  the  navel,  the  existence  of  which  had  been 


BENIGN  TUMOUKS  349 

known  to  the  patient  for  four  years.  It  was  hard,  nodular  and 
painless,  slightly  movable,  and  sub-tympanitic  on  percussion. 
No  details  are  given  of  v.  Erlach's  case,  but  since  an  operation 
was  undertaken  and  the  tumour  was  of  enormous  size  it  must 
have  been  accompanied  by  S3^mptoms  of  sufficient  severity  to 
necessitate  active  treatment. 

(2)  Fibromata. — Although  several  cases  of  '  simple  fibrous 
tumour  of  the  stomach  '  have  been  recorded,  a  careful  scrutiny 
of  the  descriptions  given  of  their  microscopic  appearances  throws 
considerable  doubt  upon  their  benign  nature.  In  some 
instances  there  is  every  reason  to  believe  that  the  growth  was 


Fig.  69. — Papilloma  of  the  pylorus.     (Museum  of  the  Eoyal 
College  of  Surgeons.) 

ordinary  scirrhous  carcinoma,  while  in  others  it  is  probable 
that  it  was  the  scar  of  a  former  ulcer  which  had  become 
keloid.  In  most  cases,  however,  where  a  circumscribed  tumour 
existed,  it  was  apparently  of  the  nature  of  a  fibro- sarcoma. 
Thus,  in  Ware's  well-known  case  a  woman  at  the  age  of  fifty- 
six  suffered  from  a  hard  irregular  tumour  of  the  abdomen 
which  extended  from  the  level  of  the  umbilicus  to  the  left 
iliac  crest.  After  death  a  fibrous  growth  was  found  to  occupy 
the  anterior  wall  of  the  stomach  near  the  great  curvature  and 
to   be   ulcerated   upon   its   mucous  aspect.1     The   absence   of 

1  Boston  Med.  and  Surg.  Journal,  1858,  p.  83. 


350  TUMOURS  OF  THE   STOMACH 

S3Tnptoras,  combined  with  the  fibrous  structure  of  the  tumour, 
appears  to  have  been  the  main  reason  for  describing  the 
growth  as  a  fibroid,  but  in  the  light  of  our  present  knowledge 
it  would  seem  to  be  fairly  typical  of  fibro-sarcoma  (p.  273).  We 
have  not  been  able  to  find  a  single  case  in  the  whole  of  the 
literature  where  a  large  fibroid  tumour  of  the  gastric  wall 
was  above  suspicion  of  malignancy. 

(3)  Lipomata  occur  as  yellow  round  or  lobulated  tumours 
in  the  wall  of  the  stomach  about  its  centre.  As  a  rule  they  form 
well-marked  projections  upon  the  inner  surface,  which  vary 
from  the  size  of  a  small  nut  to  that  of  a  pigeon's  egg,  and, 
being  situated  in  the  submucous  coat,  are  covered  by  mucous 


vi*^-''1 


Fig.  70. — Lipoma  of  the  stomach.     (London  Hospital  Museum.) 

membrane.  In  other  cases  they  originate  in  the  subserous 
connective  tissue,  and  form  large  and  somewhat  pendulous 
tumours  on  the  external  surface  of  the  organ,  near  its  lower 
margin  (Orth,  Russdorf) .  Very  rarely  the  growth  assumes  a 
more  diffuse  character  and  affects  a  large  area  of  the  gastric 
wall  (Eead).  These  tumours  are  seldom  accompanied  by  any 
special  symptoms,  but  in  the  case  of  the  large  subserous  variety 
there  may  be  a  complaint  of  weight  and  dragging,  arising  from 
the  mechanical  displacement  of  the  stomach.  It  may  also  be 
possible  to  detect  one  or  more  soft,  smooth,  painless,  and 
movable  masses  on  palpation  of  the  abdomen.  Both  varieties 
are  apt  to  become  pedunculated,  and  in  rare  instances  they  are 
converted  into  cysts  (p.  339)  or  acquire  a  malignant  character. 


BENIGN  TUMOUES  351 

(4)  Lymphadenoma  may  affect  the  stomach  and  intestines, 
either  in  the  form  of  lymphoid  overgrowths  of  the  mucous 
membrane  or  by  invasion  from  the  exterior.  In  the  former 
case  the  stomach  presents  a  number  of  sessile  and  poly- 
poid tumours,  which  are  very  numerous  and  closely  set  round 
the  cardiac  orifice  and  in  the  body  of  the  viscus,  but  are 
scanty  or  even  entirely  wanting  in  the  neighbourhood  of  the 
pylorus.  The  growths  are  soft,  smooth,  and  creamy-white  in 
colour,  and  are  intermixed  with  flattened  patches  or  vermiform 
elevations  of  lymphoid  tissue.  Occasionally  they  exhibit  signs 
of  softening  at  their  bases  (Pitt)  or  of  superficial  ulceration 
(Keimer) .  Cornil  observed  a  gangrenous  condition,  while  Kredel 
has  described  extensive  ulceration  of  the  cardia,  which  led  to 
gangrene  of  the  spleen.  The  upper  portion  of  the  duodenum  is 
usually  affected  in  a  similar  manner,  and  in  one  case  it  pre- 
sented a  growth  the  size  of  a  Tangerine  orange  (Coupland).  In 
the  small  intestine  the  solitary  glands  and  Peyer's  patches  are 
greatly  enlarged,  and  lymphoid  masses  are  often  encountered 
at  the  ileo-coecal  valve  and  around  the  vermiform  appendix. 
In  the  second  variety  the  growth,  which  has  originated  in  the 
mesenteric  glands,  forms  a  thick  sheath  over  the  intestines,  and 
by  invading  the  muscular  coat  leads  to  dilatation  of  the  bowel. 
If  the  mucous  membrane  is  involved  it  often  undergoes 
extensive  ulceration.  Microscopically,  the  lymphoid  tumours  in 
the  stomach  consist  of  mucous  membrane  which  has  been 
thrown  into  thick  folds  and  is  densely  infiltrated  with  large  and 
small  lymphocytes,  which  displace,  distort,  and  compress  the 
gastric  glands.  The  disease  is  apparently  due  to  proliferation 
of  the  normal  lymphoid  tissue  of  the  part,  and  often  leaves  the 
submucous  coat  unaffected. 

Symptoms. — The  two  varieties  differ  considerably  in  their 
clinical  features.  The  lymphoid  tumours  of  the  stomach  and 
duodenum  are  equally  frequent  in  men  and  women,  but  are 
rarely  met  with  before  middle  age,  the  most  notable  exception 
being  the  case  described  by  Kolleston  and  Latham  in  a  male 
infant  eighteen  months  old.  In  every  instance  there  is  a  general 
enlargement  of  the  lymphatic  glands,  of  the  tonsils  and  follicles 
of  the  tongue  and  pharynx,  and  of  the  spleen,  accompanied  by 
anaemia,  debility,  and  occasionally  by  inflammation  of  the 
pleura.  The  existence  of  the  growths  in  the  stomach  cannot 
be   determined   during    life,    but   the    disease   is   occasionally 


352  TUMOUES  OP  THE   STOMACH 

attended  by  diarrhoea,  and  in  Eeimer's  case  the  ulceration  of 
a  tumour  gave  rise  to  fatal  haeniatemesis.  The  second  variety 
is  far  more  common  in  males  than  in  females  (9:3),  and  is 
comparatively  frequent  in  children,  five  out  of  the  twelve 
cases  which  we  collected  being  less  than  twelve  years  of  age. 
In  every  instance  there  is  complaint  of  severe  pain  in  the 
abdomen,  breathlessness,  and  intractable  diarrhoea  ;  the  patient 
becomes  emaciated  and  suffers  from  oedema  of  the  feet,  and 
occasionally  from  jaundice  (Coupland),  and  a  well-marked 
abdominal  tumour  may  be  detected  by  palpation.  The  duration 
of  the  disease  varies  from  five  to  twelve  months,  but  in  young 
children  death  may  occur  within  the  first  three  months  (Arnott) . 
Although  some  of  these  latter  cases  are  undoubtedly  lymph- 
adenoma,  it  is  probable  that  the  majority  are  really  examples 
of  lympho-sarcoma  commencing  in  the  mesenteric  glands. 

(5)  Myxomata  occur  as  gelatinous  semi-transparent  tumours 
encapsuled  in  the  wall  of  the  stomach  and  covered  by  mucous 
membrane.  Microscopically  they  are  composed  of  elongated 
branched  cells,  which  are  embedded  in  a  homogeneous  trans- 
parent matrix.  They  are  exceedingly  rare,  and  only  three 
instances  have  been  recorded,  including  one  by  Hansemann. 
They  should  probably  be  described  as  myxosarcomata 
(Ebstein) . 

(6)  Osteomata. — Certain  tumours,  such  as  fibromata  and 
sarcomata,  occasionally  undergo  partial  ossification,  and  this 
explanation  probably  applies  to  the  following  case,  which  is 
otherwise  unique : 

Case  XLVII.  A  man,  sixty- two  years  of  age,  had  long  suffered 
from  pain  after  food  and  other  symptoms  of  indigestion,  which 
developed  at  irregular  intervals  and  terminated  in  an  attack  of 
diarrhoea.  About  five  months  before  his  death  an  attack  had  come 
on  which  proved  unusually  severe.  One  morning,  when  in  fairly 
good  health,  he  was  seized  with  violent  pain  in  the  epigastrium, 
accompanied  by  vomiting,  thirst,  constipation,  and  a  quick  pulse.  In 
the  evening  the  epigastric  region  was  found  to  be  distended  and  very 
tender.  The  vomiting  continued  urgent,  and  death  ensued  about 
twenty-two  hours  after  the  commencement  of  the  pain.  At  the 
autopsy  the  stomach  was  found  to  be  considerably  dilated.  Close  to 
the  pylorus  there  was  an  osseous  cartilaginous  tumour  the  size  and 
shape  of  a  quart -bottle  cork,  which  was  firmly  attached  by  one 
extremity  to  the  wall  of  the  stomach,  while  the  other  projected  into 


BENIGN  TUMOUBS  353 

the  pyloric  orifice  like  a  stopper.  The  mucous  membrane  over  the 
whole  stomach  was  much  inflamed. —  Webster,  'London  Medical  and 
Physical  Journal,'  1827,  2  N.  S.,  p.  433. 

(7)  Aneurysms  are  sometimes  met  with  in  the  coronary  and 
splenic  arteries,  but  they  are  seldom  larger  than  a  cherry  and 
more  often  about  the  size  of  a  pea.  They  are  also  apt  to 
develop  upon  the  base  of  a  chronic  simple  ulcer,  where  their 
rupture  is  followed  by  fatal  hEematemesis  (Powell,  Sachs, 
Welch,  Basmussen).  Cavernous  angiomata  and  lymphangio- 
mata  are  also  occasionally  encountered. 


BIBLIOGBAPHY 

Myoma 

Brodowski,  Virchow's  Archiv,  1876,  67,  p.  227. 

v.  Eiselsberg,  Arch.  f.  klin.  Chir.,  liv.  p.  568. 

v.  Erlach,  Centralbl.  f.  all.  Pathol.,  1895,  p.  240. 

Forster,  Wien.  nied.  Wochec,  1838,  ix. 

Hansemann,  Centralbl.  f.  all.  Pathol.,  1895,  p.  717. 

Herliold,  Deut.  med.  Woeh.,  1898,  p.  60. 

Jean,  Bullet.  Soe.  Anat.,  1875,  p.  20. 

Eidd,  Trans.  Path.  Soe.,  1883,  p.  196. 

Eunze,  Arch.  f.  klin.  Chirurg.,  1890,  p.  753. 

Nicoladoni,  Steiner  :  Beitrage  zu  klin.  Chir.,  xxii.  p.  1. 

Rokitansky,  Handbuch  der  pathol.  Anatomie,  iii.  p.  201. 

Ruprecht,  Arch.  f.  klin.  Chir.,  xl.  p.  756. 

Virchoiv,  Die  krankhaften  Geschwiilste,  p.  127. 

Vogel,  Icones  Histologise  Pathologicse,  p.  30,  tab.  vii. 

Wesener,  Virchow's  Archiv,  xciii.  p.  377. 

Lipoma 

Gourraud,  Journ.  de  Med.,  Chirurg.  et  Pharm.,  1790,  p.  366. 

Murray,  Trans.  Path.  Soe,  1889,  p.  78. 

OrtJi,  Lehrb.  d.  speciellen  Pathol.  Anatomie,  1887,  i.  p.  717. 

Russdorf,  Deut.  Klinik,  1867,  p.  115. 

Ulrich,  Wochen.  f.  d.  Ges.  Heilk.,  1839,  p.  525. 

Lymphadexoma 

Arnott,  Path.  Soe.  Trans.,  xxv.  p.  150. 

Barth,  Progres  Medical,  1877,  p.  784. 

Bergeron,  Union  Medicale,  1867,  ii.  p.  555. 

Briquet,  Cruveilhier's  Atlas,  54,  plates  2  and  3. 

Carrington,  Path.  Soe.  Trans.,  xxxv.  p.  386. 

Chvostek,  Allg.  Wien.  med.  Zeitung,  1877,  p.  14. 

Coupland,  Path.  Soe.  Trans.,  xxviii.  p.  127 ;  ibid.  xxix.  p.  363. 

Fagge,  Catalogue  of  Guy's  Hosp.  Museum. 

A  A 


354  TUMOUKS  OP  THE   STOMACH 

Gilly,  La  Lymphadenie  Intestinale.     These,  Paris  1886. 

Haclden,  Path.  Soc.  Trans.,  xxxvii.  p.  261 ;  ibid,  xxxix.  p.  128. 

Eelsch,  Bull.  Soc.  Anat.,  1873,  p.  558. 

Kredel,  Berl.  klin.  Woch.,  1883,  p.  769. 

Langhans,  Virchow's  Archiv,  liv.  p.  509. 

Moore,  Path.  Soc.  Trans.,  xxxiv.  p.  99. 

Moxon,  Path.  Soc.  Trans.,  xxiv.  p.  101. 

Murchison,  Path.  Soc.  Trans.,  xx.  p.  192. 

Pitt,  Path.  Soc.  Trans.,  xl.  p.  80. 

Rolleston  &  Latham,  Lancet,  1898,  i.  p.  1313. 

Silcock,  Path.  Soc.  Trans  ,  xxxv.  p.  348. 

Taylor,  Path.  Soc.  Trans.,  xxviii.  p.  135. 


INDEX 


Abdomen,  enlarged  veins  of,  147 

inspection  of,  146 

shape  of,  146 

visible  peristalsis  in,  147 

visible  tumour  of,  147 
Abdominal  tumour  in  cancer,  164 

characters  of,  166 

frequency  of,  166 
Abdominal  wall,  metastases  in,  163 
Abscess,  perigastric,  45,  178 

boundaries  of,  46 

complications  of,  48,  180 

frequency  of,  46 

signs  of,  179 

symptoms  of,  179 
Acetone  in  the  urine,  141 
Acid,    hydrochloric,   in    cancerous   sto- 
mach, 151 

frequency  of,  152 

significance  of,  152 

tests  for,  153 
Acid,  lactic,  in  cancerous  stomach,  154 
Acidity  in  gastric  cancer,  129 

treatment  of,  257 
Acute  cancer,  222 
Adeno-carcinoma,  13 

frequency  of,  22 

histology  of,  32 
Adenoma  of  stomach,  301 

pedunculated,  304 

symptoms  of,  308 

treatment  of,  311 
Adhesions  in  gastric  cancer,  33 

effects  of,  35 

frequency  of,  33 

organs  involved  in,  34 
Age  in  gastric  cancer,  86 
Albuminuria  in  gastric  cancer,  75,  141 

gastric  sarcoma,  277 
Alcohol,  influence  of,  on  cancer,  98 
Anaemia  in  cancer,  133 

causes  of,  133 

nature  of,  133 

varieties  of,  133 
Anaemic  form  of  gastric  cancer,  210 

diagnosis  of,  245 

varieties  of,  210 


Anasarca  in  cancer,  143 

general,  144 
Aneurysm  complicating  cancer,  73,  170 
Aneurysms  of  stomach,  353 
Angiomata,  353 
Angiosarcoma,  274 
Anorexia  in  cancer,  125 

causes  of,  125 

frequency  of,  125 

treatment  of,  255 
Apoplexy  in  cancer,  105 
Appetite,  disorders  of,  125 
Arterial  disease  in  cancer,  68,  73 
Arteries,  thrombosis  of,  72,  189 
Artificial  inflation  of  stomach,  148 
Ascites  in  gastric  cancer,  70 

bilious,  70 

causes  of,  70 

chylous,  70 

diagnosis  of,  185,  207 

frequency  of,  70 

hemorrhagic,  70 

signs  of,  185 

symptoms  of,  184 

varieties  of,  70,  184 
Ascitic  form  of  gastric  cancer,  207 

diagnosis  of,  246 
Aspect  in  gastric  cancer,  145 
Atheroma  in  cancer,  73 
Atypical  mitoses,  160 
Axillary  glands,  enlargement  of,  175 


Bacillus,  Oppler-Boas,  in  cancer,  157 
in  sarcoma,  280 

Benign  growths  in  cancer,  103 

Benign  tumours  of  stomach,  347 

Bezoars,  324 

Bibliography  of  benign  tumours,  353 

concretions  in  the  stomach,  334 
cysts  of  stomach,  346 
duodenal  cancer,  299 

sarcoma,  300 
gastric  cancer,  262 
polypi  of  stomach,  311 
sarcoma  of  stomach,  282 
syphilis  of  stomach,  322 


356       CAXCEE  AND  TUMOURS  OF  THE   STOMACH 


Bigastric  fistula.  51 

Blood  cysts  of  stomach,  336 

Blood,  state  of,  in  cancer,  133 

Body  of  stomach,  tumours  of,  173 

Bowels,  state  of,  in  cancer,  129 

Brain,  disease  of,  in  cancer,  69,  142, 189 

Bright' s  disease  in  cancer,  75,  141 

Bruits  over  a  gastric  tumour,  171 


Cachectic  purpura,  193 
Cachexia  of  cancer,  133 

causes  of,  133 
Cancer  tissue  in  gastric  contents,  157 

vomit,  118,  157 
Carcinoma  invading  simple  ulcer,  216 
Carcinoma,  modes  of  diffusion  of,  57 
Carcinoma  of  body  of  stomach,  198 

diagnosis  of,  240 

signs  of,  199 

special  symptoms  of,  198 

surgical  treatment  of,  261 
Carcinoma  of  cardiac  orifice,  194 

diagnosis  of,  196,  235 

results  of,  196 

signs  of,  196 

symptoms  of,  194 

treatment  of,  251,  261 
Carcinoma  of  duodenum,  284 

diagnosis  of,  297 

frequency  of,  284 

primary,  284 

secondary,  285 

symptoms  of,  286 

treatment  of,  299 

varieties  of,  286 
Carcinoma  of  pylorus,  199 

diagnosis  of,  237 

signs  of,  200 

special  symptoms  of,  199 

surgical  treatment  of,  258 
Carcinoma  of  stomach,  1 

acute,  222 

age  in,  86 

anaemia  in,  133 

anaemic  form  of,  210 

anorexia  in,  125 

ascites  in,  70,  185,  207 

bibliography  of,  262 

blood  in,  133 

bowels  in,  129 

cachexia  in,  133 

climatic  influences  in,  100 

clinical  varieties  of,  194 

coma  in,  143 

complications  of,  177 

contagion  in,  92 

course  of,  223 

diagnosis  of,  231 

diet  in,  96 

disorders  of  digestion  in,  124 

duration  of,  225 


Carcinoma    of    stomach,  dysphagia  in, 

125 
enlargement  of  glands  in,  175 
etiology  of,  78 
fistula?  in,  49,  180 
flatulence  in,  127 
gastric  contents  in,  151 
geographical  distribution  of,  90 
haemorrhage  in,  42,  120 
heredity  in,  94 
histology  of,  27 
hydrochloric  acid  in,  151 
increase  of,  81 
in  early  life,  88,  222 
intestinal  obstruction  in,  130 
jaundice  in,  69,  187 
lactic  acid  in,  154 
latent,  203 
leuchaemia  in,  214 
loss  of  flesh  in,  131 
loss  of  strength  in,  130 
metastases  in,  53, 182 
mortality  from,  79 
multiple  growths  of,  23 
nausea  in,  127 

nervous  symptoms  in,  142, 190 
onset  of,  107 
originating  in  ulcer,  216 
pain  in,  110 
palpation  in,  160 
perforation  in,  177 
perigastric  abscess  in,  178 
pernicious  anaemia  in,  213 
physical  signs  of,  145 
precocious   development    of,    88, 

222 
prognosis  of,  229 
purpura  in,  193 
pyrosis  in,  129 
race  in,  93 
saliva  in,  139 
secondary,  24 
secondary      inflammations      in. 

190 
septicaemia  in,  193 
sequelae  of,  33 
sex  in,  85 
situation  of,  21 
superficial  metastases  in,  163 
symptoms  of,  106 
temperature  in,  135 
tetany  in,  193 
thrombosis  in,  71,  188 
tongue  in, 129 
topography  of,  91 
traumatism  in,  99 
treatment  of,  251 
ulceration  in,  40 
urine  in,  140 
varieties  of,  2 
vomiting  in,  115 
Cardia,  stenosis  of,  194 


INDEX 


357 


Cardia,  stenosis  of,  diagnosis  of,  235 

signs  of,  196 
Cardia,  tumours  of,  173 
Cerebral  complications  of  cancer,  143, 

189,  191 
Characters  of  tumour  in  cancer,  166 

from  hair-balls,  328 

in  sarcoma,  277 
Chlorides  in  urine  in  cancer,  142 
Chylous  ascites,  70 
Chylous  cysts  of  stomach,  339 
Climatic  influences  in  cancer,  90,  100 
Clinical  varieties  of  gastric  cancer,  194 
Colloid  carcinoma,  15 

frequency  of,  19 

histology  of,  32 
Colon,  condition  of,  in  gastric  cancer,  77 
Coma  carcinomatosum,  143 

causes  of,  143 

symptoms  of,  143 
Combined  hydrochloric  acid  in  cancerous 

stomach,  154 
Complications  of  gastric  cancer,  177 
Concretions  in  stomach,  324 
Condurango,  use  of,  255 
Congestion   of   face  in   gastric   cancer, 

145 
Constipation  in  gastric  cancer,  129 

treatment  of,  257 
Contagion  in  cancer,  92 
Contraction  of  stomach,  38 
Course  of  gastric  cancer,  223 
Curettage  of  stomach,  159 
Cysts  of  stomach,  335 

bibliography  of,  346 

blood,  336 

chylous,  339 

dermoid,  335 

diagnosis  of,  343 

from  new  growths,  339 

hydatid,  336 

serous,  335 

signs  of,  342 

symptoms  of,  342 

treatment  of,  345 
Cysts,  retro-peritoneal,  344 


Delieium  in  cancer,  142 
Dermoid  cysts,  335 
Diagnosis  of  duodenal  cancer,  297 
gastric  cancer,  231 

differential,  235 

early,  233 

general,  231 
gastric  concretions,  332 

cysts,  343 

polypi,  311 

sarcoma,  281 

syphilis,  319 

tumours,  236,  238,  240, 243 
Diarrhcea  in  gastric  cancer,  130 


Diet  as  cause  of  cancer,  96 
Diet  in  gastric  cancer,  254 
Digestion,  disorders  of,  in  cancer,  124 
Digestion-leucocytosis,  134 
Dilatation  of  the  stomach  in  cancer,  36 

causes  of,  37 

frequency  of,  37 
Disappearance  of  gastric  tumours,  170, 

171 
Duodenum,  carcinoma  of,  284 

complications  of,  290,  296 

diagnosis  of,  297 

duration  of,  296 

etiology  of,  286 

frequency  of,  284 

intestinal  obstruction  in,  293 

multiple,  286 

secondary,  57,  285 

signs  of,  289,  294 

symptoms  of,  286 

toxaemia  in,  293 

treatment  of,  299 

varieties  of,  284 
Duodenum,  sarcoma  of,  286 
Dyspepsia  in  gastric  cancer,  124 

preceding  gastric  cancer,  102 
Dyspeptic  form  of  gastric  cancer,  209 
Dysphagia  in  gastric  cancer,  125 

causes  of,  126 

reflex,  126 


Early  diagnosis  of  gastric  cancer,  233 
Emaciation,  rapidity  of,  131 
Endocarditis  in  gastric  cancer,  73 

ulcerative,  73 
Enlargement  of  glands,  175,  187 

superficial  veins,  147 
Enteritis  in  gastric  cancer,  190 
Entire  stomach,  cancer  of,  200 

tumours  from,  174 
Etiology  of  gastric  cancer,  78 

sarcoma,  276 
Examination  of  abdomen,  146 
Examination  of  stomach,  148 

methods  of,  148 


Face,  congestion  of,  in  cancer,  145 
Failure  of  strength  in  cancer,  130 
Fatal   hffimatemesis   in   gastric  cancer, 

44,  124 
Fever  in  gastric  cancer,  135 

causes  of,  137 

continuous,  136 

occasional,  135 

varieties  of,  135 
Fibroma  of  stomach,  349 

pedunculated,  305 
Fistula?,  external,  51 

internal,  49 

symptoms  of,  180 


358       CANCEE  AND  TUMOUES  OF  THE    STOMACH 


Flatulence  in  gastric  cancer,  127 

causes  of,  128 

symptoms  of,  127 

treatment  of,  256 
Flesh,  loss  of,  in  cancer,  131 
Fragments  of  cancer  in  vomit,  119,  157 
Frequency  of  gastric  cancer,  78 
Fundus,  tumours  of,  173 


Gall-bladder,  cancer  of,  49 

fistula  of,  49 

rupture  of,  291 
Gases  of  stomach,  128 
Gastric  contents,  examination  of,  151 

free  hydrochloric  acid  in,  151 

lactic  acid  in,  154 

pepsin  in,  156 

rennet  in,  156 
Gastritis  in  cancer,  76,  190 

pathology  of,  76 

symptoms  of,  209 

treatment  of,  256 

varieties  of,  76 
Gastritis,  syphilitic,  314 
Gastro-colic  fistulas,  49,  180 

causation  of,  50 

diagnosis  of,  181 

frequency  of,  49,  180 

symptoms  of,  180 
Gastro-cutaneous  fistulas,  51,  181 

signs  of,  182 
Gastro-diaphany,  149 
Gastro-duodenal  fistula,  50 
Gastroenterostomy  in  cancer,  259 

indications  for,  261 
Gastroliths,  325 

symptoms  of,  331 
General  anasarca  in  gastric  cancer,  144 
Generalisation  of  cancer,  67 
General  peritonitis  from  perforation  of 
stomach,  174 

in  cancer,  66,  177, 184 
Geographical    distribution    of     gastric 

cancer,  90 
Glands,  cancerous  infection  of,  56,  61 

metastases  in,  56,  187 

symptoms  of,  187 
Gummata  of  the  stomach,  313 


H^matemesis  in  gastric  cancer,  42,  120 

as  first  symptom  of,  109 

fatal,  124 

frequency  of,  120 

symptoms  of,  121 

treatment  of,  257 

varieties  of,  120 
in  gastric  sarcoma,  278 
Haemoglobin  in  gastric  cancer,  134 
Haemorrhage  in  gastric  cancer,  42,  120 

causes  of,  42 


Haemorrhage  in  gastric  cancer,  varieties 

of,  42,  120 
Hair-balls  in  stomach,  324 

appearances  of,  324 

bibliography  of,  334 

complications  of,  328 

diagnosis  of,  332 

duration  of,  328 

etiology  of,  326 

signs  of,  327 

symptoms  of,  327 

treatment  of,  332 

tumours  from  328 
Heart  in  gastric  cancer,  73 

atrophy  of,  73 

fatty  disease  of,  73 

size  of,  73 
Heredity  in  cancer,  94 
Histology  of  cancer,  27 
Hour-glass  stomach,  15,  38 
Hydatids  of  stomach,  336 
Hydrochloric  acid  in  cancerous  stomach, 
151 

failure  of,  153 

frequency  of,  152 

tests  for,  153 
Hydronephrosis  in  gastric  cancer,  75 
Hydrothorax  in  gastric  cancer,  73 
Hygiene,  defective,  as  cause  of  cancer, 
99 

Icterus  in  duodenal  cancer,  288 
Icterus  in  gastric  cancer,  69,  187 

causes  of,  187 

frequency  of,  187 

signs  of,  188 
Idiopathic  anaemia  with  gastric  cancer, 

213 
Improvement  in  gastric  cancer,  132 
Increase  of  cancer,  81 

weight  in  gastric  cancer,  224 
Indican  in  urine,  141 
Inflammation  of  intestine,  77,  190 

kidney,  75,  190 

lungs,  74,  190 

stomach,  76,  190 
Inflation,  artificial,  of  stomach,  148 

influence  on  tumours,  169 
Influence  of  seasons  on  development  of 

cancer,  100 
Inguinal  glands,  enlargement  of,  175 
Insanity  in  gastric  cancer,  105 
Insomnia,  142 
Inspection  of  abdomen,  146 
Intestinal  fistulae,  49 

obstruction   in  cancer,   130,  187, 
293 
Intestine,  metastases  of,  56,  58,  187 

Jaundice  in  duodenal  cancer,  288 
gastric  cancer,  69,  187 


INDEX 


359 


Jejunum,  invasion  of,  by  cancer,  77 
Juxta-jejunal  cancer,  292 


Kidneys,  state  of,  in  gastric  cancer,  75 
inflammation  of,  76 

symptoms  of,  190 


Lactic  acid  in  cancerous  stomach,  154 

causes  of,  155 

frequency  of,  155 

significance  of,  155 

tests  for,  155 
Latent  cancer  of  stomach,  203 

causes  of,  203 

symptoms  of,  203 

varieties  of,  203 
Lavage  in  gastric  cancer,  252 
Leucheemic  cancer,  214 
Leucocytosis  in  gastric  cancer,  134 

digestion-,  134 
Liability  of  stomach  to  cancer,  79,  81 
Lipoma  of  stomach,  350 

pedunculated,  305 
Liver  in  gastric  cancer,  75 
Liver,  metastases  in,  55,  182 

frequency  of,  55 

signs  of,  184 

symptoms  of,  183 
Loss  of  flesh  in  cancer,  130 
Lymphadenoma  of  stomach,  351 

symptoms  of,  351 

varieties  of,  351 
Lymphangioma  of  stomach,  339 
Lymphatic  glands,  enlargement  of,  175 

metastases  in,  54,  187 
Lymphatic  infection  in  cancer,  61 
Lymphatics  of  stomach,  61 
Lymphosarcoma  of  intestine,  286,  351 

of  stomach,  272 


Malaria  and  cancer,  104 
Malignant  ulcer  of  stomach,  11 
Mania  in  gastric  cancer,  191 
Mediastinal  glands,  enlargement  of,  55, 

175 
Medullary  cancer,  8 
Melama  in  gastric  cancer,  42,  120 
Melancholia  in  gastric  cancer,  190 
Mental  states  in  gastric  cancer,  142,  190 
Metastases,  53 

frequency  of,  54 

modes  of  origin  of,  56 

organs  affected  by,  54 

signs  and  symptoms  of,  182 
Metastases  in  brain,  55,  191 

glands,  175 

intestine,  186 

liver,  182 

lungs,  186 


Metastases  in  muscles,  164 

peritoneum,  184 

skin,  164,  165 
Metastases  in  gastric  sarcoma,  274 
Micro-organisms  in  stomach,  157 
Microscopical    examination    of    gastric 
contents,  157 

features  of  cancer,  27 
Mobility  of  gastric  tumours,  168 
Morbid  anatomy  of  cancer,  1 
Mucous      membrane      expelled      from 

stomach,  158 
Mucous  polypi,  301 

appearances  of,  301 

bibliography  of,  311 

complications  of,  309 

diagnosis  of,  311 

etiology  of,  303 

frequency  of,  301 

histology  of,  302 

symptoms  of,  306 

treatment  of,  311 
Multiple  cancers,  23 
Murmurs  over  tumours,  171 
Muscles,  metastases  of,  164 

wasting  of,  132 
Myoma  of  stomach,  347 

pedunculated,  306 

symptoms  of,  348 
Myosarcomata,  274 
Myxosarcomata,  352 


Nausea  in  gastric  cancer,  127 
Navel,  secondary  growths  of,  148 

retraction  of,  148 
Nervous  complications  of  gastric  cancer, 
190 

symptoms  in  gastric  cancer,  142 
Neuritis  in  cancer,  191 
New  growths,  cysts  from,  339 
Non-detection  of  gastric  tumours,  166 
Nutrient  enemata,  253 


Obstruction  of  intestine  in  cancer,  130, 

293 
Obstruction  of  oesophagus,  57,  59,  125 

signs  of,  150, 196 
Occupation  as  cause  of  cancer,  96 
(Edema  in  cancer,  143 
(Esophagus,    conditions   of,    in   gastric 

cancer,  76 
Onset  of  gastric  cancer,  107 
Operative    treatment  of  gastric  cancer, 
258 
sarcoma,  282 
Opium  in  cancer,  256 
Oppler-Boas  bacillus,  157 
Osteoma  of  stomach,  352 
Oxybutyric  acid  in  urine,  141 


360      CANCEE  AND   TUMOUKS   OF  THE    STOMACH 


Pain  in  gastric  cancer,  110 

access  of,  111 

as  first  symptom,  108 

cause  of,  112 

effect  of  posture  on,  112 

influences  which  affect,  112-114 

radiations  of,  110 

situation  of,  110 

treatment  of,  256 
Palpation  of  abdomen,  160 

modes  of,  162 

tenderness  on,  ]62 
Papilloma  of  stomach,  305,  348 
Paralysis  in  gastric  cancer,  142,  191 
Parapyloric  cancer,  287 
Pedunculated  adenomata,  301,  304 

fibromata,  305 

lipomata,  305 

myomata,  306 
Pedunculated  tumours,  301 
Pepsin,  estimation  of,  156 

secretion  of,  156 
Peptonuria  in  cancer,  141 
Perforation  of  colon,  49,  180 

skin,  51,  181 

solid  viscera,  48 
Perforation  of  stomach  from  hair-balls, 

329 
Perforation  of  stomach   in  cancer,  44, 
177 

peculiarities  of,  52 

symptoms  of,  177 
Perforation      of     stomach    in     benign 
tumours,  309 

in  sarcoma,  280 

in  syphilis,  313 
Periampullary  cancer,  288 
Perigastric  abscess,  45 

frequency  of,  178 

results  of,  180 

signs  of,  179 

symptoms  of,  179 

varieties  of,  178 
Peripheral  neuritis  in  cancer,  191 
Peritoneum,  metastases  of,  66,  184 

frequency  of,  55,  184 

signs  of,  185 

symptoms  of,  184 
Peritoneum,  miliary  carcinosis  of,  184 

ascites  from,  70,  185 

diagnosis  of,  185 

signs  of,  184 

symptoms  of,  185 
Peritoneum,  secondary  cancer  of,  55, 184 
Peritonitis,  acute,  in  gastric  cancer,  45, 
177 

causes  of,  177,  184 

diagnosis  of,  185 

frequency  of,  145,  177 

symptoms  of,  178 
Peritonitis,  cancerous,  diagnosis  of,  185 

tumours-in,  186 


Pernicious  anaemia  with  cancer,  213 
Physical  signs  of  gastric  cancer,  145 
Pleura,  carcinoma  of,  73,  186 

diseases  of,  in  cancer,  73 
Pleurisy,  acute,  73 

varieties  of,  73 
Pneumonia  in  gastric  cancer,  74,  190 
Polyadenomata,  301 
Polypi  of  stomach,  301 

mucous,  301 

symptoms  of,  306 

varieties  of,  301 
Portal  thrombosis,  188 
Precocious  development  of  cancer,  88 
Prognosis  in  cancer,  229 
Pulmonary  disease  in  cancer,  73 
Pulsation  of  gastric  tumours,  170 
Purpura  in  cancer,  193 
Pylorectomy,  258 

contra-indications  to,  259 

results  of,  259 
Pylorus,  cancer  of,  199 
Pylorus,  tumours  of,  171 

frequency  of,  171 

mobility  of,  172 

position  of,  172 

shape  of,  172 
Pyrexia  in  gastric  cancer,  135 

causes  of,  137 

frequency  of,  135 
Pyrosis,  129 

Eace,  influence  of,  in  cancer,  93 
Eeceptaculum  chyli,  cancer  of,  65 
Rectal  feeding,  253 
Eed  corpuscles  in  cancer,  133 
Referred  pain  in  gastric  cancer,  162 
Eenal  diseases  in  gastric  cancer,  75 
Eennet,  secretion  of,  157 
Eespiratory  organs,  diseases  of,  73 
Extraction  of  navel,  148 
Eheumatism  and  cancer,  104 


Saliva  in  gastric  cancer,  136 

examination  of,  140 
importance  of,  140 
Sarcoma  of  the  duodenum,  286 

secondary,  286 
Sarcoma  of  the  stomach,  271 

angio-,  267 

bibliography  of,  282 

blood  in,  277 

complications  of,  280 

diagnosis  of,  281 

distinction  of,  from  cancer,  275 

duration  of,  280 

etiology  of,  276 

frequency  of,  271 

haemorrhage  in,  278 

metastases  in,  274 


INDEX 


361 


Sarcoma  of  the  stomach,  rnyo-,  274 

round-cell,  272 

signs  of,  279 

spindle-cell,  273 

symptoms  of,  277 

treatment  of,  282 

varieties  of,  271 
Scirrhus,  2,  30 

Seasons,  influence  of,  on  cancer,  100 
Secondary  carcinoma  of  stomach,  24,  25 
Secondary  growths  in  gastric  cancer,  53 

symptoms  of,  182 
Secondary  inflammation  in  cancer,  190 
SepticEemia  in  gastric  cancer,  137,  193 
Sequelas  of  cancer,  33 
Serous  cysts  of  stomach,  335 
Sex  in  gastric  cancer,  85 
Shape  of  stomach,  changes  in,  36 

tumours,  167 
Situation  of  growths  in  stomach,  21 

pain  in  gastric  cancer,  110 

tumours,  167 
Size  of  cancerous  tumours,  166 
Skin,  metastases  of,  in  cancer,  164 

sarcoma,  279 
Skin,  perforation  of,  51,  181 
Spheroidal-celled  carcinoma,  2,  32 
Spinal  disease  in  gastric  cancer,  191 
Spindle-celled  sarcoma,  273 
Spleen,  condition  of,  in  cancer,  74 
Spleen,  enlargement  of,  in  cancer,  214 

sarcoma,  281 
Spleen,  secondary  cancer  of,  49 
Stenosis  of  cardiac  orifice,  150,  196 

pylorus,  199 
Stomach,  cancer  of,  1 

clinical  varieties  of,  194 

complications  of,  177 

diagnosis  of,  231 

etiology  of,  78 

histology  of,  27 

morbid  anatomy  of,  1 

physical  signs  of,  145 

prognosis  of,  229 

sequelas  of,  33 

symptoms  of,  106 

treatment  of,  251 
Stomach,  aneurysms  of,  353 

angioma  of,  353 

angiosarcoma  of,  274 

artificial  inflation  of,  148 

auscultatory  percussion  of,  148 

benign  tumours  of,  347 

contraction  of,  38 

cysts  of,  335 

dilatation  of,  36,  148 

examination  of,  148 

exploration  of,  with  a  tube,  149 

fibroma  of,  305,  349 

gummata  of,  313 

hair-balls  in,  324 

hour-glass,  38 


Stomach,  irregular  deformities  of,  38 

lipomata  of,  305,  350 

lymphadenoma  of,  351 

lymphatics  of,  61 

myoma  of,  306,  347 

myosarcoma  of,  274 

myxoma  of,  352 

myxosarcoma  of,  272 

normal  situation  of,  165 

osteoma  of,  352 

pedunculated  tumours  of,  301 

polypi  of,  301 

sarcoma  of.  271 

stones  in,  325 

syphilis  of,  313 

syphilitic  inflammation  of,  314 

trans-illumination  of,  149 

tumours  of,  166,  271 
Streptococci  in  stomach,  193 
Subdiaphragmatic  abscess,  178 
Suicide  in  cancer,  142 
Sulphocyanide  of   potassium  in  saliva, 
139 

significance  of,  140,  229 
Supra-ampullary  cancer,  287 
Supra-clavicular  glands,  enlargement  of. 
175 

significance  of,  175,  187 
Surgical  treatment  of  cancer,  258 

hair-balls  in  stomach,   333 

sarcoma,  282 

tumours,  311 
Syphilis  and  cancer,  104 
Syphilis  of  stomach,  313 

bibliography  of,  322 

diagnosis  of,  319 

endarteritis  in,  314 

forms  of,  313 

gastritis  in,  314 

gummata  in,  313 

symptoms  of,  316 

treatment  of,  321 

ulceration  in,  313 
Syphilitic  gastritis,  314 

ulcer,  313 


Temperature  in  gastric  cancer,  135 

Test  meals,  151 

Tests  for  blood  in  vomit,  121 

hydrochloric  acid,  153 

lactic  acid,  156 

pepsin,  156 

rennet,  157 
Tetany  in  cancer,  191 

sarcoma,  281 
Thoracic  duct,  cancer  of,  67 
Thrombosis,  arterial,  72,  189 
Thrombosis  of  veins  in  cancer,  71,  188 

causes  of,  71,  189 

frequency  of,  71 

results  of,  189 


B  B 


362       CANCEE  AND  TUMOUES  OP  THE   STOMACH 


Thrombosis  of  veins  in  cancer,  suppu- 
rative, 72,  189 

symptoms  of,  188 
Tongue  in  cancer,  129 
Topography  of  cancer,  91 
Trans-illumination  of  stomach,  149 
Traumatism  and  cancer,  99 
Treatment  of  duodenal  cancer,  299 
Treatment  of  gastric  cancer,  251 

diet  in,  254 

general,  251 

lavage  in,  252 

local,  252 

medicinal,  255 

rectal  feeding  in,  253 

sedatives  in,  256 

surgical,  258 
Treatment  of  gastric  sarcoma,  282 

syphilis,  321 

tumours,  311 
Tube,  employment  of,  149 

in  diagnosis,  150 

in  treatment,  252 
Tumours  in  simple  ulcer,  243 
Tumours  of  cardia,  173,  236 

entire  stomach,  174,  201 

fundus,  173,  236 

gastric  walls,  173,  241 
Tumours  of  pylorus,  171,  238 
Tumours  of  stomach,  benign,  347 

cystic,  335 

from  hair-balls,  328 

in  sarcoma,  279 

pedunculated,  321 
Tumours  of  stomach  in  cancer,  164 

alterations  in  shape  of,  171 

alterations  in  size  of,  169 

auscultation  of,  171 

causes  of  non-detection  of,  166 

diagnosis  of,  236,  238,  241 

disappearance  of,  171 

frequency  of,  166 

mobility  of,  168 

percussion  of,  171 

pulsation  of,  170 

shape  of,  167 

situation  of,  167 

size  of,  166 

special  features  of,  171 

tenderness  of,  168 


Ulcer,  cancerous  invasion  of,  216 
Ulcer  of  stomach  from  concretions,  329 
Ulcer  of  stomach  in  cancer,  40,  41 

sarcoma,  273 

syphilis,  313 


Ulcer  of  stomach  in  tumours,  309 
Ulcus  carcinomatosum,  216 

frequency  of,  216 

symptoms  of,  217 

varieties  of,  217 
Umbilicus,  retraction  of,  in  cancer,  148 

secondary  growths  of,  148 
Urea,   secretion  of,   in   gastric   cancer, 

141 
Urine  in  duodenal  cancer,  293 
Urine  in  gastric  cancer,  140 

acetone  in,  141 

albumin  in,  141 

chlorides  in,  142 

indican  in,  141 

oxybutyria  acid  in,  141 

peptones  in,  141 

secretion  of,  140 

urea  in,  141 

urobilin  in,  141 
Urobilin  in  cancer  of  liver,  141,  183 
Uterus,  relative  liability  of,  to  cancer, 
81 


Valvular  disease  in  gastric  cancer,  73 
Vascular  infection  in  cancer,  67 
Vegetable  tumours  in  stomach,  330 
Vegetarians  and  cancer,  97 
Veins,  enlargement  of,  147 

thrombosis  of,  71,  188 
Vessels  eroded  in  gastric  cancer,  44 
Visible  gastric  peristalsis,  147 

tumours  of  stomach,  147,  167 
Vomit,  characters  of,  in  cancer,  118 

detection  of  blood  in,  121 

morbid  growths  in,  119 
Vomiting  in  gastric  cancer,  115 

absence  of,  115 

as  first  symptom  of,  107 

causes  of,  116 

character  of,  116 

faecal,  119, 180 

frequency  of,  115 

spontaneous  subsidence  of,  118 

treatment  of,  256 

varieties  of,  115 
Vomiting  of  bile  in  duodenal  cancer,  293 

blood  in  cancer,  120 


Wall  of  stomach,  tumour  of,  173 
Wasting  of  heart  in  cancer,  73 

soft  tissues,  131,  132 

spleen,  74 
Water-brash,  129 
White  corpuscles  in  cancer,  134 


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